Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders

OBJECTIVE: Although several treatments for adolescent substance abuse have been identified as promising by reviewers and federal agencies, treatment effects extending beyond 12 months have not been demonstrated in randomized clinical trials. The primary purpose of this report was to examine the 4-year outcomes of an evidence-based treatment of substance-abusing juvenile offenders. METHOD: Eighty of 118 substance-abusing juvenile offenders participated in a follow-up 4 years after taking part in a randomized clinical trial comparing multisystemic therapy (MST) with usual community services. A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of the participating young adults. RESULTS: Analyses demonstrated significant long-term treatment effects for aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes. Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of marijuana abstinence for MST participants (55% versus 28% of young adults). Long-term treatment effects were not observed for psychiatric symptoms. CONCLUSIONS: Findings provide some support for the long-term effectiveness of an evidenced-based family-oriented treatment of substance-abusing juvenile offenders. The clinical, research, and policy implications of these findings are noted.     

Cerebrovascular disease in young, HIV-infected, black Africans in the KwaZulu Natal province of South Africa

The objective of this study was to elucidate the mechanisms of an ischemic stroke in a human immunodeficiency virus, type 1 (HIV)-infected population. Several clinical and autopsy studies have suggested an increased incidence of strokes in HIV-infected persons. These studies have been performed on diverse populations with numerous confounds for strokes, including, drug abuse and coexistent opportunistic infection. Because of these confounding factors, it has been difficult to assess whether a unique stroke propensity exists among HIV-infected persons. A retrospective case-controlled study was carried out of patients registered in the Durban Stroke Data Bank (DSDB) (n=1298) located in KwaZulu Natal province of South Africa. Sixteen per cent of all strokes in young (<50 year old) black Africans living in KwaZulu Natal province on the east coast of South Africa reported to the DSDB occurred in association with HIV infection. This HIV-infected population was free of drug abuse and relatively devoid of opportunistic infections. The incidence rate of HIV in this stroke population paralleled that of the young black population at large, suggesting no significant overall increased rate of stroke in association with HIV. However, when compared to strokes occurring in an age- and sex-matched, HIV-seronegative control population, the cryptogenic stroke was more common in the HIV-infected population. Although the incidence of rate of stroke appeared to be no higher among HIV-infected young black Africans in the KwaZulu province than among HIV-seronegative controls, the increased incidence of a large vessel cryptogenic stroke in the former suggests the presence of a co-existent prothromobotic state.     

Level of agreement between DIS and UM-CIDI alcohol and marijuana use disorders: implications for research

By and large, recent epidemiological investigations of alcohol and drug use disorders are based on structured interviews, such as the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI), which are designed to be administered by trained lay interviewers. Little is known about the level of agreement between these instruments. To fill this gap, we compared responses from 971 young adults from an epidemiological sample, who were administered both the DIS and the University of Michigan CIDI (UM-CIDI) in the same interview session. Level of agreement was estimated for responses to individual items, and for DSM-IIIR abuse/dependence (A/D) diagnoses and symptoms for alcohol and marijuana. DIS/UM-CIDI agreement for drug use disorders in the year preceding the interview was moderate for each disorder (alcohol A/D, kappa = 0.58; marijuana A/D, kappa = 0.68), although one-year prevalences of alcohol and marijuana A/D were approximately 40% higher for the DIS compared to the UM-CIDI. Despite the discrepancies, levels of comorbidity with other psychiatric disorders and associations with risk factors were similar for the DIS and UM-CIDI. Copyright © 1999 Whurr Publishers Ltd.     

Arterial dissection and stroke following child abuse: case report and review of the literature

Introduction Arterial dissection and stroke following trauma are seen frequently. Although similar mechanisms occur for trauma and child abuse, no reports of stroke have been observed in the literature.Case reports Two patients successively presented to our institution with acute onset of neurological deficit and stroke. Further evaluation disclosed child abuse as an underlying condition leading to the strokes. Child protection services were contacted immediately after admission of the patients and further measures were taken.Conclusions Recognition of potential cases of child abuse is crucial. Early intervention and cessation of interaction between the aggressor and the child are important measures to be taken in all situations when there is strong evidence of suggestive examination of child abuse.     

Aspirin and Clopidogrel for Prevention of Ischemic Stroke

Cerebrovascular disorders contribute to the morbidity and disability associated with illicit drug use. Drug abusers have an increased risk of both hemorrhagic and ischemic stroke. In geographic areas with a high prevalence of illicit drug use, drug abuse is a frequent cause of stroke in the young adult. The illicit drugs more commonly associated with stroke are psychomotor stimulants, such as amphetamine and cocaine. Less commonly implicated are opioids and psychotomimetic drugs, including cannabis. Toxicology screening for illicit drugs should be done in young patients with stroke with no obvious cause, or if suggested by history or examination. Although in some patients the mechanism of stroke is identified using neuroimaging and other modern diagnostic tools, in a sizeable fraction of cases the mechanism of stroke remains unclear. Further studies are needed to elucidate the role of hemodynamic and immunologic mechanisms in these cases.     

Ischemic stroke in a young patient with methylephedrine addiction: a case report]

We report a case of a young patient who had an ischemic stroke due to methylephedrine addiction. A 39-year-old man was admitted to our hospital because of right hemiplegia and persistent numbness. Brain diffusion-weighted magnetic resonance images demonstrated multiple hyperintensity spots in the deep and superficial borderzone area of the left hemisphere. The patient had no obvious diseases that might have caused ischemic stroke, including potential cardiac sources of embolism, vasculopathy of the cerebral artery, or abnormalities of blood coagulation. However, we found that the patient had started to abuse methylephedrine at the age of 20 years old, and we suspected that drug abuse might have caused his ischemic stroke. Although previous reports have associated ischemic stroke with ephedrine, no reports have related this condition to methylephedrine. However, our case suggests that methylephedrine abuse may cause ischemic stroke.     

Stroke in young adults who abuse amphetamines or cocaine: a population-based study of hospitalized patients

CONTEXT: The abuse of stimulant drugs is increasing in the western United States. Although numerous case reports and animal studies suggest a link with stroke, epidemiologic studies have yielded conflicting results. OBJECTIVE: To test the hypothesis that young adults who abuse amphetamines or cocaine are at a higher risk of stroke. Design, Setting, and PARTICIPANTS: Using a cross-sectional design and from a quality indicators' database of 3 148 165 discharges from Texas hospitals, we estimated the secular trends from January 1, 2000, to December 31, 2003, in the abuse of various drugs and of strokes. We developed separate logistic regression models of risk factors for hemorrhagic (n = 937) and ischemic (n = 998) stroke discharges of persons aged 18 to 44 years in 2003, and for mortality risk in patients with stroke. Main Outcome Measure Incidence of stroke using definitions from the Agency for Healthcare Research and Quality's stroke mortality Inpatient Quality Indicator. RESULTS: From 2000 to 2003, the rate of increase was greatest for abuse of amphetamines, followed by cannabis and cocaine. The rate of strokes also increased, particularly among amphetamine abusers. In 812 247 discharges in 2003, amphetamine abuse was associated with hemorrhagic stroke (adjusted odds ratio [OR], 4.95; 95% confidence interval [CI], 3.24-7.55), but not with ischemic stroke; cocaine abuse was associated with hemorrhagic (OR, 2.33; 95% CI, 1.74-3.11) and ischemic (OR, 2.03; 95% CI, 1.48-2.79) stroke. Amphetamine, but not cocaine, abuse was associated with a higher risk of death after hemorrhagic stroke (OR, 2.63; 95% CI, 1.07-6.50). CONCLUSION: Increases in stimulant drug abuse may increase the rate of hospital admissions for strokes and stroke-related mortality.     

Abused to abuser: antecedents of socially deviant behaviors

The authors interviewed 34 young people who had been sexually abused as children 6 or 8 years after the abuse had occurred and compared them with 34 control subjects who had not been abused. They also compared subjects who had been abused for less than 1 year with those who had been abused for more than 1 year. The findings suggest a link between childhood sexual abuse and later drug abuse, juvenile delinquency, and criminal behavior. The authors explore the effects of pretrauma factors of previous childhood physical abuse and parental modeling of aggression and the postdisclosure factors of social and family blaming.     

Activated protein C resistance in young African American patients with ischemic stroke.

BACKGROUND: It has been proposed that activated protein C resistance (APCR) due to the factor V Leiden (FVL) mutation may be a risk factor for stroke in young adults. However, this may not be the case for all ethnic groups due to variability in the prevalence of the FVL mutation. METHODS: Case series from a university neurology clinic. Patients with an APCR ratio of 2.2 or below were tested for the FVL mutation (nine patients). Patients on warfarin were also tested for the FVL mutation (14 patients). RESULTS: 38 African American patients under age 55 with an arterial stroke were identified. The mean age of the patients is 43.1 years. Five percent had an APCR ratio of 2.0 or below. None of the patients with an APCR ratio of 2.2 or below or the patients directly tested for the FVL mutation had the mutant allele. CONCLUSIONS: Activated protein C resistance due to the FVL mutation does not appear to be a major risk factor for stroke in young African Americans. Other, as yet unidentified, mechanisms leading to activated protein C resistance may be important in a small subset of young African American stroke patients.     

Visual hallucination associated with anterior cerebral artery occlusion

The author experienced two cases who showed visual hallucinations after they had had CT-proven cerebral infarctions in the left fronto-medial lobe. Cerebral angiography evidenced the occlusion of the left anterior cerebral artery at the genu portion (case 1) and after branching the frontopolar artery (case 2). Case 1 was a 50 year old national rail way officer who had neither past history of a drug abuse nor that of psychoses. His initial symptom was right hemiparesis predominantly in his lower extremity. Mutism and sympathetic apraxia were also observed. About three months after the onset, he showed psychical excitement due to his curious experience of seeing dogs and snakes in the window and ceiling of his hospital room. A famous professional golf player was also seen. This hallucination lasted about three weeks and never occurred afterwards. Case 2 was a 70 year old housewife who was noticed abnormal by her family because of her mutism of sudden onset. Clumsiness of her extremities was also seen. She had nothing to do with a drug abuse and psychoses. Three days after the onset her mutism turned into talkativeness. She complained of seeing dead persons, who were hanging and coming from the ceiling of her room. Animals and familiar landscapes were also seen. This hallucination lasted about a week. In both cases hallucinations were vivid and colorful. Patients were basically critical for the phenomena although they were initially influenced and excited by them. Temporal and occipital lobes have been thought to bo responsible for the occurrence of organic hallucinations in supratentorial lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neurological complications of drug abuse: pathophysiological mechanisms

Drug abuse is associated with a variety of neurological complications. The use of certain recreational drugs shows a marked temporal association with the onset of both haemorrhagic and ischaemic strokes, the majority of which develop within minutes to 1 h after the administration of the index drug. Delayed onset of stroke has also been observed. Acute, severe elevation of blood pressure, cardiac dysrhythmias, cerebral vasospasm, vasculitis, embolization due to infective endocarditis or dilated cardiomyopathy, embolization due to foreign material injected with the diluents under non-sterile conditions and 'street drug' contaminants with cardiovascular effects have been suggested as possible underlying mechanisms. Rupture of aneurysms and arteriovenous malformations have been detected in up to half of the patients with haemorrhagic stroke due to cocaine abuse. The less common findings reported have included a mycotic cerebrovascular aneurysm in a patient with infective endocarditis and haemorrhagic stroke. In addition to stroke, cocaine seems to provoke vascular headache. Seizures precipitated by recreational drug abuse are usually caused by acute intoxication in contrast to the withdrawal seizures encountered in subjects with alcohol abuse. Movement disorders and cerebral atrophy correlating with the duration of abuse have been described. Snorting of organic solvents may cause encephalopathy. Cases of spongiform leukoencephalopathy in heroin addicts have also been reported. Peripheral neuropathy is occasionally precipitated by drug poisoning after intravenous administration. Impurities of the drug, risky administration techniques, and the use of mixtures of various drugs, frequently with simultaneous alcohol drinking, should be taken into account when assessing the background of the adverse event as well as the overall lifestyle of the addicted subjects.     

Spinal epidural abscess with a rapid course in young healthy infantry recruits with multiple skin lacerations

In recent years, there has been high prevalence of Staphylococcus aureus (S. aureus) infection among soldiers in the Israeli military, with devastating sequelae in several cases. Emergency department physicians have developed a high level of suspicion for spinal epidural abscess (SEA) in patients presenting known risk factors; however, SEA is a particularly elusive diagnosis in young healthy adults with no history of drug abuse. We review three cases of SEA secondary to methicillin-sensitive S. aureus (MSSA) infection in young healthy soldiers without known risk factors. We retrospectively reviewed clinical files of soldiers treated at our Medical Center from 2004–2015 to identify patients diagnosed with SEA. Those aged less than 30 years with no history of intravenous drug use, spine surgery or spine trauma were included in the study. Three young army recruits met the inclusion criteria. These young men developed SEA through extension of MSSA infection to proximal skin and soft tissue from impetigo secondary to skin scratches sustained during “basic” training. All presented with mild nuchal rigidity and severe persistent unremitting lancinating radicular pain. Although healthy at baseline, they had a severe, rapidly progressive course. Following urgent surgery, two patients recovered after rehabilitation; one remained with paraparesis at late follow-up. Neurological deficits and systemic evidence of S. aureus infection progressed rapidly in these young healthy SEA patients with no history of drug abuse, emphasizing the critical role of timely MRI, diagnosis, and surgery.     

Substance abuse and cerebral blood flow

OBJECTIVE AND METHOD: This paper reviews acute and chronic effects of drugs of abuse on cerebral blood flow (CBF) and metabolism and their clinical significance. The most important source of information for the review is human research reports published in refereed journals. A few animal studies, book chapters, and abstracts that are especially relevant are also included. RESULTS: In humans, ethanol in small doses produces cerebral vasodilation; higher doses induce cerebral vasoconstriction. Chronic alcoholism is associated with reduced CBF and cerebral metabolism. Sedatives and antianxiety drugs lead to global reduction in CBF and cerebral metabolism. Caffeine, even in small doses, is a potent cerebral vasoconstrictor. Cerebral vasodilation is seen immediately after cigarette smoking, but chronic smokers show global reduction in CBF. Changes in CBF after marijuana smoking are variable; both increases and decreases are seen. Chronic marijuana smoking, however, seems to reduce CBF. Most inhalants and solvents are vasodilators; chronic abuse is accompanied by a decrease in CBF. A number of drugs of abuse, including ethanol, amphetamines, cocaine, nicotine, and caffeine-phenylpropanolamine combinations, increase the risk for stroke. Reduction in CBF associated with chronic use of ethanol, nicotine, inhalants, and solvents is at least partially reversible upon abstinence. CONCLUSIONS: Topics for future research include regional brain function, which mediates drug-induced mood changes (euphoria); CBF concomitants of psychological and physiological characteristics that increase addiction potential; changes in CBF that accompany withdrawal syndromes; mechanisms responsible for drug-induced stroke; and effects of functional and organic complications on CBF.     

Long-term neuropsychological deficits after cerebellar infarctions in two young adult twins

Two young adult dizygotic twins with high schooling suffered two strokes at the ages of 26 and 30 years. On the first occasion, Case 2 suffered a stroke only a few months after Case 1; on the second occasion, Case 1 suffered a second stroke a few months after Case 2. In Case 1, lesions were mainly localized to the left cerebellar hemisphere in both stroke episodes. Case 2 suffered lesions localized to the right cerebellar hemisphere in the first stroke episode, and multiple lesions in both cerebellar hemispheres and the vermis, right pons and left thalamus during the second stroke episode. Seven years after the second stroke, despite full recovery of motor functions, the patients still show mild, yet selective, linguistic deficits (syntactic comprehension deficits, mild agrammatism, reading and writing disorders) without speech disturbances. They also present with selective dysfunctions in visuospatial short-term memory. Language disorders are ascribed to a dysfunction of the cerebellum in Case 1, while in Case 2 a dysfunction of the cerebellum and the thalamus is considered as both structures are part of the so-called 'frontal lobe system', which supports language generation. Visuospatial short-term memory disorders are attributed to an impaired ability to appreciate the organizing structure of the visual task and to poor planning strategies, which are in turn ascribed to cerebellar lesions. The role of the cerebellum in cognitive and linguistic functions is discussed.     

Use of substance abuse services by young uninsured american adults

OBJECTIVES: This study examined the prevalence and correlates of substance abuse service use among uninsured young adults aged 18 to 34 years (N=24,282). METHODS: Data were drawn from the 1999 National Household Survey on Drug Abuse. Logistic regression was used to identify correlates of substance abuse service use among persons who met DSM-IV criteria for dependence. RESULTS: Among uninsured young adults (N=5,067), 66 percent lacked any health care coverage for at least one year. In this uninsured group, 72 percent were past-year users of alcohol or drugs (N=2,335). Among past-year alcohol users (N=2,273), 12 percent met criteria for alcohol dependence; among past-year drug users (N=864), 21 percent met dependence criteria. Eighty-seven percent of the uninsured young adults with alcohol or drug dependence did not receive any substance abuse treatment services in the previous year. In the uninsured substance-dependent group, women, blacks, and Hispanics were less likely than men and whites to use substance abuse services. Among those with substance dependence, uninsured persons were more likely than privately insured persons to receive substance abuse services from the self-help or human service (nonmedical) sector. Conclusions: Racial, ethnic, and gender disparities in the use of substance abuse services are notable among young adults who lack health insurance.     

The Harvard Twin Study of Substance Abuse: what we have learned

The Harvard Twin Study of Substance Abuse was carried out with the members of the Vietnam Era Twin (VET) Registry. The VET Registry comprises over 8000 male twins who served in the United States military between 1965 and 1975 and were subsequently interviewed regarding their use of licit and illicit substances, as well as various types of psychopathology. Our research has demonstrated significant influences by genetic, shared environmental, and unique environmental factors on the abuse of illicit substances. Multivariate analyses have indicated that the co-occurrence of abuse of various types of illicit drugs reflects a common vulnerability, influenced by both genetic and environmental factors, that cuts across all categories of illicit drugs. We have also demonstrated that some drugs have unique determinants, both genetic and environmental, that are not shared with other drugs. In part, the genetic influence on marijuana abuse is mediated by genetic influence on subjective effects in response to the drug. The determinants of transitions from one stage of drug use to another differ depending on which drug or which transition is examined. We determined significant genetic influences on several aspects of nicotine and alcohol use separately, as well as genetic influences shared by both substances. We found that the co-occurrence of illicit drug abuse and major depression is due to unique environmental influences. The phenotypic association between symptoms of conduct disorder and alcohol and marijuana dependence is due largely to shared environmental influences. Our results, thus far, indicate a complex pattern of genetic and environmental influences on substance use and abuse.     

Seven year follow-up of 300 young drug abusers

300 young morphine addicts in Copenhagen were personally followed up 7 years after their first referral for treatment. The tracking rate was 93.7%. Of the original population, approximately 2% died yearly, i.e. 16%. Each year 5-6% ceased drug abuse, and in 1980, 39% were characterized as being socially well adjusted. In all, 20% remained heavy drug users, though some had changed to other drugs.     

青年脑卒中病因及危险因素的研究进展

近年来关于青年卒中的报道逐渐增加,青年卒中的发病率越来越高。青年卒中不但严重影响患者的生活质量及工作,而且给家庭及社会造成沉重的经济负担。青年卒中的病因与老年人相比更加复杂。对于青年卒中,虽然有些病因及危险因素是先天性的,是不可预防和控制的,例如先天性脑血管畸形、脑淀粉样血管病;但是多数病因及危险因素还是可预防和控制的,例如高血压、糖尿病、吸烟、饮酒等。然而,遗憾的是这些病因及危险因素在发病前大多不被人知晓或重视,以至最终造成脑血管病发病越来越年轻化。探讨青年卒中的病因及危险因素对及早预防具有重要意义。