Cheryl Newman

Use of multiple drugs among adolescents who use anabolic steroids

BACKGROUND Because adolescent users of anabolic steroids are concerned with increasing muscle size and strength, they may be unique among substance users and unlikely to use other drugs. Alternatively, if the factors that cause the use of anabolic steroids are similar to those associated with the use of other substances, adolescents who use anabolic steroids would be expected to report use of other drugs as well. METHODS We administered a questionnaire based on the 1989 Secondary School Health Risk Survey and the 1990 Youth Risk Behavior Survey of the Centers for Disease Control and Prevention to 1881 students enrolled in compulsory health-science classes (mean [+/- SD] age, 14.9 +/- 1.0 years) in the Richmond County, Georgia, school system. RESULTS A higher percentage of boys (6.5 percent) than girls (1.9 percent, P < or = 0.001) reported using anabolic steroids without a doctors prescription. Among ninth-grade students only, 5.4 percent of boys and 1.5 percent of girls reported using anabolic steroids (P < or = 0.001). Among users of anabolic steroids, 25 percent reported sharing needles to inject drugs. The frequency of anabolic-steroid use was significantly (P < 0.001) associated with the frequency of use in the previous 30 days of cocaine (r = 0.44), injectable drugs, alcohol (r = 0.23), marijuana (r = 0.42), cigarettes (r = 0.25), and smokeless tobacco (r = 0.40). On the basis of multiple regression analysis, the use of marijuana, shared needles, smokeless tobacco, and cocaine accounted for 33 percent of the variation in anabolic-steroid use among the ninth-grade students. CONCLUSIONS In our study, adolescent users of anabolic steroids were likely to use other drugs as well, and many were sharing needles.

Candida Urinary Tract Infections—Treatment

In many instances a report from the clinical laboratory indicating candiduria represents colonization or procurement contamination of the specimen and not invasive candidiasis. Even if infection of the urinary tract by Candida species can be confirmed, antifungal therapy is not always warranted. Further investigation may reveal predisposing factors, which if corrected or treated, result in the resolution of the infection. For those with symptomatic urinary tract infections (UTIs), the choice of antifungal agent will depend upon the clinical status of the patient, the site of infection, and the pharmacokinetics and pharmacodynamics of the agent. Because of its safety, achievement of high concentrations in the urine, and availability in both an oral and intravenous formulation, fluconazole is preferred for the treatment of Candida UTIs. Flucytosine is concentrated in urine and has broad activity against Candida spp, but its use requires caution because of toxicity. Low-dose amphotericin B may be useful for Candida UTIs in selected patients. The role of echinocandins and azoles that do not achieve measurable concentrations in the urine is not clear. Small case series note some success, but failures have also occurred. Irrigation of the bladder with antifungal agents has limited utility. However, with fungus balls, irrigation of the renal pelvis through a nephrostomy tube can be useful in combination with systemic antifungal agents.

Candida Urinary Tract Infections—Epidemiology

Candiduria is rarely present in healthy individuals. In contrast, it is a common finding in hospitalized patients, especially those in intensive care units (ICUs) who often have multiple predisposing factors, including diabetes mellitus, indwelling urinary catheters, and exposure to antimicrobials. Candiduria occurs much less commonly in the community setting. In a majority of episodes in adult patients in critical care facilities candiduria represents colonization, and antifungal therapy is not required. However, the presence of yeast in the urine can be a sign of a disseminated infection. In the critically ill newborn, candiduria often reflects disseminated candidiasis and is accompanied by obstructing fungus ball formation in the urinary tract. In ICU patients, although candiduria is a marker for increased mortality, it is only rarely attributable to Candida urinary tract infection.

Treatment of Blastomycosis with Higher Doses of Fluconazole

Recent clinical data suggest that fluconazole at daily doses of 200 to 400 mg for at least 6 months is moderately effective therapy for non-life-threatening blastomycosis. To examine the usefulness of higher doses of fluconazole therapy for this disorder, we conducted a multicenter, randomized, open-label study to determine the efficacy and safety of two different daily doses of fluconazole (400 and 800 mg) in the treatment of non-life-threatening blastomycosis. Of 39 patients evaluable for efficacy analysis, 34 (87%) were successfully treated, including 89% and 85% of patients who received 400 and 800 mg, respectively. Five (83%) of six patients for whom prior antifungal therapy had failed were successfully treated. The mean duration of therapy was 8.9 months for successfully treated patients. Nineteen patients (48%) reported adverse events, although most were minor. We conclude that fluconazole at daily doses of 400 to 800 mg for at least 6 months is effective therapy for non-life-threatening blastomycosis.

Candida Urinary Tract Infections—Diagnosis

The finding of candiduria in a patient with or without symptoms should be neither dismissed nor hastily treated, but requires a careful evaluation, which should proceed in a logical fashion. Symptoms of Candida pyelonephritis, cystitis, prostatitis, or epididymo-orchitis are little different from those of the same infections produced by other pathogens. Candiduria occurring in critically ill patients should initially be regarded as a marker for the possibility of invasive candidiasis. The first step in evaluation is to verify funguria by repeating the urinalysis and urine culture. Pyuria is a nonspecific finding; the morphology of the offending yeast may allow separation of Candida glabrata from other species. Candida casts in the urine are indicative of renal candidiasis but are rarely seen. With respect to culture, colony counts have not proved to be diagnostically useful. In symptomatic or critically ill patients with candiduria, ultrasonography of the kidneys and collecting systems is the preferred initial study. However, computed tomography (CT) is better able to discern pyelonephritis or perinephric abscess. The role of magnetic resonance imaging and renal scintigraphy is ill defined, and prudent physicians should consult with colleagues in the departments of radiology and urology to determine the optimal studies in candiduric patients who require in-depth evaluation.

Candida urinary tract infection: pathogenesis.

Candida species are unusual causes of urinary tract infection (UTI) in healthy individuals, but common in the hospital setting or among patients with predisposing diseases and structural abnormalities of the kidney and collecting system. The urinary tract may be invaded in either an antegrade fashion from the bloodstream or retrograde via the urethra and bladder. Candida species employ a repertoire of virulence factors, including phenotypic switching, dimorphism, galvano - and thigmotropism, and hydrolytic enzymes, to colonize and then invade the urinary tract. Antegrade infection occurs primarily among patients predisposed to candidemia. The process of adherence to and invasion of the glomerulus, renal blood vessels, and renal tubules by Candida species was elegantly described in early histopathologic studies. Armed with modern molecular biologic techniques, the various virulence factors involved in bloodborne infection of the kidney are gradually being elucidated. Disturbances of urine flow, whether congenital or acquired, instrumentation of the urinary tract, diabetes mellitus, antimicrobial therapy, and immunosuppression underlie most instances of retrograde Candida UTI. In addition, bacterial UTIs caused by Enterobacteriaceae may facilitate the initial step in the process. Ascending infections generally do not result in candidemia in the absence of obstruction.

Telemedicine diagnosis of eye disorders by direct ophthalmoscopy ☆: A pilot study

OBJECTIVE To report a pilot study of telemedical direct ophthalmoscopy in the diagnosis of acquired immune deficiency syndrome (AIDS)-related retinopathy in a human immunodeficiency virus (HIV)-positive population and in the diagnosis of glaucoma, cataract, and retinopathy in a diabetic population. DESIGN Prospective comparative case series. PARTICIPANTS Seventeen HIV-positive and 20 diabetic patients. METHODS A direct ophthalmoscope custom-fitted with a digital microcamera capable of transmitting images from any of 61 sites within the Georgia Statewide Telemedicine Program was used by a nonophthalmologist to examine 34 eyes of 17 HIV-positive patients and 39 eyes of 20 patients with diabetes. Fundus images were transmitted in real-time to a reviewing ophthalmologist. An in-person, comprehensive examination including indirect ophthalmoscopy, was performed by a second ophthalmologist. Telemedical examination was compared to the in-person comprehensive examination. RESULTS For the HIV study, 21 eyes did not show HIV retinopathy (noninfectious retinopathy with cotton-wool spots) by in-person examination. Telemedical examination correctly identified 20 of these eyes as disease-free (specificity = 95%). HIV retinopathy was present in 12 of the 34 eyes by in-person evaluation with telemedical examination correctly diagnosing 10 of these eyes (sensitivity = 83%). One eye with dense cataract and retinal detachment was unable to be evaluated ophthalmoscopically by either in-person or telemedical examination. Telemedical and in-person assessments for HIV retinopathy were identical in 100% of eyes without cataract. Disagreement in diagnosis between telemedical and in-person examination was associated with cataract (P < 0.0007). For the diabetes study, because of an inadequate image, telemedical examination was unable to classify 46% and 36% of eyes for glaucoma and diabetic retinopathy, respectively. Inability to make a telemedical determination for glaucoma (P < 0.011), nonproliferative (P < 0.064) and proliferative (P < 0.064) diabetic retinopathy was associated with cataract. Of the eyes that were able to be assessed by telemedical examination for diabetic retinopathy (n = 25), glaucoma (n = 21), and cataract (n = 39), the accuracy was poor (sensitivity = 29%, 50%, and 41%, respectively). Telemedical examination for diabetic retinopathy and glaucoma was more likely to agree with in-person examination in eyes without cataract as compared to eyes with cataract (not statistically significant). CONCLUSION Telemedical direct ophthalmoscopic, real-time fundus imaging may provide a valuable means for providing ophthalmic consultation to the primary care physician in younger patients without lens or media opacity, but is inadequate for eyes with any degree of lens or media opacity.

Stability of the relationships between anabolic steroid use and multiple substance use among adolescents

BACKGROUND In a previous study, we tested the hypothesis that because adolescent anabolic steroid users are concerned with increasing muscle size and strength they are different from other substance users and are unlikely to use other drugs. Alternatively, if the causal factors of anabolic steroid use are similar to those for use of other substances, then adolescent anabolic steroid users would be expected to report poly drug use. Study findings confirmed the second hypothesis. PURPOSE To test the stability of the relationships between anabolic steroid use and poly drug use over a four month period among ninth grade students. METHODS All ninth grade students (1422) enrolled in compulsory health science classes in a country school system who had previously completed a modified version of the Centers for Disease Control and Preventions 1989 Health Risk Survey and the 1990 Youth Risk Behavior Survey in November 1990 were asked to repeat the survey in February 1991. RESULTS A higher percentage of males (4.7 percent) than females (2.9 percent, P < or = 0.018) reported anabolic steroid use without a doctors prescription. As was found in the initial study, frequency of anabolic steroid use was significantly (P < 0.001) associated with frequency of use in the last 30 days of cocaine, injectable drugs, alcohol, marijuana, cigarettes, and smokeless tobacco. When those variables were analyzed with multiple regression analysis, the same four variables continued to be the best predictors of the frequency of anabolic steroid use, although the order that the variables entered into the multiple regression model changed. Use of smokeless tobacco, shared needles, cocaine, and marijuana explained more variation in the frequency of anabolic steroid use in the replication study (48.5%) than initially (32.8%). CONCLUSIONS These findings support the hypothesis that adolescent anabolic steroid users are also likely to use other drugs and are engaging in shared needle use. These relationships remained relatively stable over a four month period of time.

An evaluation of a school-based AIDS/HIV education program for high school students

The effect of a 1-hr school-based AIDS/HIV education program on the knowledge and attitudes of high school students was evaluated with a modified version of the Centers for Disease Control Health Risk Survey. One urban and one suburban school each were randomly assigned to an educational intervention (n = 535) or a control group (n = 659). All students received a posttest 2 weeks after the intervention. Knowledge was based on responses to 12 true-false questions (pretest alpha = .76, posttest alpha = 0.81). Principal components analysis was used to develop three attitude scales and risk-taking behavior was assessed by self-report. Data were analyzed with Kruskall-Wallis analysis of variance (ANOVA) and multivariate ANOVA. The groups did not differ in knowledge level at pretest. At posttest the education group had significantly (p < or = 0.006) higher knowledge even after controlling for the effects of previous AIDS education (p < or = 0.019), gender (p < or = 0.007), and Hispanic ethnicity (p < or = 0.048). After the education program, students were less worried about exposure to the AIDS virus, but were more worried (p < or = 0.048) about AIDS acquisition during their adult life. Although single school-based AIDS/HIV education programs may increase knowledge, more extensive education may be needed to change the behavior and attitudes of older high school students.

Application of random amplified polymorphic DNA PCR for genomic analysis of HIV-1-infected individuals

Random amplified polymorphic DNA polymerase chain reaction (RAPD-PCR) is a DNA fingerprinting technique used to detect genomic polymorphisms. We employed sixteen different RAPD-PCR 10-mer primers to amplify DNA from the peripheral blood mononuclear cells (PBMC) of 80 HIV-1-infected individuals. These individuals were previously identified as either heterozygotes (+ /delta32) and homozygotes (+/+) for the CCR5 locus by PCR with gene specific primers. Four of the sixteen randomly selected RAPD primers produced distinguishable banding profiles between CCR5 (+/delta32) heterozygotes and CCR5 (+/+ ) homozygotes. Direct sequencing of some RAPD-PCR products obtained with one of the four RAPD primers that were tested yielded clearly readable, but limited sequences, which were similar to portions of the previously published sequences for (+/+ ) homozygotes (98% similarity) and (+/delta32) heterozygotes (87% similarity) of the CCR5 alleles. Thus, the RAPD-PCR technique may be useful for the identification of human molecular markers that may correlate with susceptibility to HIV-1-infection, or differences in disease progression among HIV-l-infected individuals.