Findings from the DUMA program: methamphetamine drug market trends

Introduction Methamphetamine is a drug of national concern, with the Australian Crime Commission assessing it to be the illicit drug posing the greatest risk to the Australian community. The Australian Institute of Health and Welfare’s (AIHW) 2013 National Drug Strategy Household Survey (NDSHS) reported that approximately 400,000 Australians had used meth/amphetamines in the previous 12 months. The NDSHS reported a stable rate of meth/amphetamine use in the general community from 2010 to 2013 of 2.1 percent. However, there was a shift in the type of meth/amphetamine used, from powder to purer forms like ice or crystal methamphetamine. Specifically, powder meth/amphetamine use among recent users decreased from 51 percent to 29 percent, while ice use more than doubled from 22 percent to 50 percent. In line with this, the frequency of methamphetamine use among injecting drug users in Melbourne remained consistent from 2008 to 2014, but users reported transitioning from powder to crystal forms of methamphetamine. Frequency of use of methamphetamine has also changed across the 2010 to 2013 period. In 2013, 15.5 percent of recent meth/amphetamine users reported daily or weekly use, compared with 9.3 percent in the 2010 survey. When examining use by form, approximately a quarter of users who mainly used ice reported using it at least weekly, compared with 2.2 percent of powder users who reported weekly use. Scott et al.’s study of injecting drug users in Melbourne found that those already using methamphetamine were starting to purchase the drug more frequently in 2013 compared with 2011

Findings from the DUMA program: impact of reduced methamphetamine supply on consumption of illicit drugs and alcohol

This paper presents an analysis of retrospective self-reports from methamphetamine users (police detainees) on the impact that periods of reduced methamphetamine supply had on reported consumption of methamphetamine, alcohol and other illicit drugs. Introduction Changes in illicit drug availability have been shown to impact users’ alcohol and other drug consumption. In late 2000 and early 2001, Australia experienced a sudden and dramatic reduction in the supply of heroin which has continued to the present date. This shortage has been attributed to, at least in part, supply-side reduction strategies undertaken by law enforcement. However, the benefits associated with this shortage were to some degree offset by the unintended consequence of displacement in illicit drug use, reflected in an increase in the use of other drugs, such as cocaine. Research into the impact of the heroin shortage on illicit drug users has resulted in an awareness of the need to understand potential unintended outcomes of supply-side drug law enforcement strategies

Findings from the DUMA program: drink and drug driving among police detainees

This paper finds that detainees do perceive a risk related to drink and drug driving, in terms of impairment in driving ability and potential detection by police. These conditions are likely to result in deterrence from drink and drug driving for some detainees. Introduction In Australia, random breath testing (RBT) was introduced in the mid-1970s to detect drivers under the influence of alcohol. This resulted in a reduction in fatal crashes and alcohol-related traffic accidents across Australia. The success of RBT can be explained through the classic deterrence doctrine, which suggests that decision-making is influenced by the perception of whether the benefits of the crime outweigh the risks of being caught. The introduction of RBT arguably increased the perceived and real risk of being caught, which positively influenced individuals’ decisions to refrain from driving while intoxicated. Following the successful implementation of RBT, between 2004 (in Victoria) and 2011 (in the Australian Capital Territory), random roadside drug testing (RRDT) was introduced across Australia. The aim of RRDT was to deter drug driving, decreasing both the prevalence of drug driving and the associated harms. In 2013, data from the Australian Institute of Health and Welfare (AIHW) indicated that drug driving and drink driving had been engaged in by more than one in 10 Australians (16% and 12% respectively) surveyed during the previous 12 months. Rates of drug driving are even higher in populations where illicit drug use is common, such as among police detainees, where 65 percent of detainees surveyed reported driving while under the influence of alcohol and/or drugs in the previous 12 months. Examining perceptions of risk of drug driving, in terms of both being caught and legitimacy (perceptions of impairment to driving ability), will identify whether the preconditions exist to support drug driving deterrence through RRDT

HIV Treatment in a Conflict Setting: Outcomes and Experiences from Bukavu, Democratic Republic of the Congo

Providing HIV care in conflict settings involves additional obstacles to those generally encountered in other resource-limited settings, say Heather Culbert and colleagues

Systematic review: what interventions improve dignity for older patients in hospital?

Aims and objectives. To review the evidence for interventions to improve dignity for older patients in acute care.Background. High profile cases have highlighted failure to provide dignified carefor older people in hospitals. There is good evidence on what older people con-sider is important for dignified care and abundant recommendations on improvingdignity, but it is unclear which interventions are effective.Design. Narrative systematic review.Methods. The Cochrane library, MEDLINE, EMBASE, CINAHL, BNI andHMIC electronic databases were searched for intervention studies of any designaiming to improve inpatients’ dignity. The main population of interest was olderpatients, but the search included all patients. Studies that focused on ‘dignity ther-apy’ were excluded.Results. There were no intervention studies found in any country which aimed toimprove patient dignity in hospitals which included evaluation of the effect. Anarrative overview of papers that described implementing dignity interventions inpractice but included no formal evaluation was, therefore, undertaken. Fivepapers were identified. Three themes were identified: knowing the person; part-nership between older people and health care professionals; and, effective commu-nication and clinical leadership. The effect on dignity of improving these isuntested.Conclusions. There are currently no studies that have tested interventions toimprove the dignity of older people (nor anyone else) in hospitals. Furtherresearch using well designed trials of interventions is needed. There is also a needto develop and validate outcome measures for interventions to improve dignity.Relevance to clinical practice. At present nurses lack robust evidence on how to improve dignity. There is ample evidence on what undermines patients’ dignit

Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices

BACKGROUND. The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis. METHODS. A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects. RESULTS. Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries. CONCLUSIONS. This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries

Glycogen Synthase Kinase 3 (GSK3) Inhibitor, SB-216763, Promotes Pluripotency in Mouse Embryonic Stem Cells

Canonical Wnt/β-catenin signaling has been suggested to promote self-renewal of pluripotent mouse and human embryonic stem cells. Here, we show that SB-216763, a glycogen synthase kinase-3 (GSK3) inhibitor, can maintain mouse embryonic stem cells (mESCs) in a pluripotent state in the absence of exogenous leukemia inhibitory factor (LIF) when cultured on mouse embryonic fibroblasts (MEFs). MESCs maintained with SB-216763 for one month were morphologically indistinguishable from LIF-treated mESCs and expressed pluripotent-specific genes Oct4, Sox2, and Nanog. Furthermore, Nanog immunostaining was more homogenous in SB-216763-treated colonies compared to LIF. Embryoid bodies (EBs) prepared from these mESCs expressed early-stage markers for all three germ layers, and could efficiently differentiate into cardiac-like cells and MAP2-immunoreactive neurons. To our knowledge, SB-216763 is the first GSK3 inhibitor that can promote self-renewal of mESC co-cultured with MEFs for more than two months

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Phenotypic Characterization of EIF2AK4 Mutation Carriers in a Large Cohort of Patients Diagnosed Clinically With Pulmonary Arterial Hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a rare disease with an emerging genetic basis. Heterozygous mutations in the gene encoding the bone morphogenetic protein receptor type 2 (BMPR2) are the commonest genetic cause of PAH, whereas biallelic mutations in the eukaryotic translation initiation factor 2 alpha kinase 4 gene (EIF2AK4) are described in pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Here, we determine the frequency of these mutations and define the genotype-phenotype characteristics in a large cohort of patients diagnosed clinically with PAH. METHODS: Whole-genome sequencing was performed on DNA from patients with idiopathic and heritable PAH and with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis recruited to the National Institute of Health Research BioResource-Rare Diseases study. Heterozygous variants in BMPR2 and biallelic EIF2AK4 variants with a minor allele frequency of <1:10 000 in control data sets and predicted to be deleterious (by combined annotation-dependent depletion, PolyPhen-2, and sorting intolerant from tolerant predictions) were identified as potentially causal. Phenotype data from the time of diagnosis were also captured. RESULTS: Eight hundred sixty-four patients with idiopathic or heritable PAH and 16 with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis were recruited. Mutations in BMPR2 were identified in 130 patients (14.8%). Biallelic mutations in EIF2AK4 were identified in 5 patients with a clinical diagnosis of pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Furthermore, 9 patients with a clinical diagnosis of PAH carried biallelic EIF2AK4 mutations. These patients had a reduced transfer coefficient for carbon monoxide (Kco; 33% [interquartile range, 30%-35%] predicted) and younger age at diagnosis (29 years; interquartile range, 23-38 years) and more interlobular septal thickening and mediastinal lymphadenopathy on computed tomography of the chest compared with patients with PAH without EIF2AK4 mutations. However, radiological assessment alone could not accurately identify biallelic EIF2AK4 mutation carriers. Patients with PAH with biallelic EIF2AK4 mutations had a shorter survival. CONCLUSIONS: Biallelic EIF2AK4 mutations are found in patients classified clinically as having idiopathic and heritable PAH. These patients cannot be identified reliably by computed tomography, but a low Kco and a young age at diagnosis suggests the underlying molecular diagnosis. Genetic testing can identify these misclassified patients, allowing appropriate management and early referral for lung transplantation