A randomized controlled trial of buprenorphine in the management of short-term ambulatory heroin withdrawal

Aim: To determine whether buprenorphine is more effective than clondine and other symptomatic medications in managing ambulatory heroin withdrawal.
Design: Open label. prospective randomized controlled trial examining
withdrawal and 4-week postwithdrawal outcomes on intention-to-treat.
Setting: Two specialist, out-patient drug treatment centres in inner city
Melbourne and Sydney, Australia.
Participants: One hundred and fourteen dependent heroin users were recruited. Participants were 18 yea rs or over. and with no significant other drug dependence, medical or psychiatric conditions or recent methadone treatment. One hundred and one (89%) participants completed a day 8 research interview examining withdrawal outcomes, and 92 (81%) completed day 35 research interview examining postwithdrawal outcomes.
Interventions: Participants randomized to control (n = 56) (up to 8 days or
clonidine and other symptomatic medications) or experimental (n = 58) (up to 5 days of buprenorphine) withdrawal groups. Following the 8-day withdrawal episode, participants could self-select from range of postwithdrawal options (naltrexone, substitution maintenance or counselling).
Measurements: Retention in withdrawal: heroin use during withdrawl: and
retention in drug treatment 4 weeks after withdrawal.
Secondary outcomes: Withdrawal severity: adverse events, and heroin use in the postwithdrawal period.
Findings: The experimental group had better treatment retention at day 8 (86% versus 57%, P = 0.001, 95% CI for numbers needed to treat (NNT) = 3-8) and day 35 (62% versus 39%, P = 0.02, 95% CI for NNT = 4-18): used heroin on fewer days during the withdralwal programlme (2.6 ± 2.5 versus 4.5 ± 2. 3.
P < 0.001. 95% CI = 1- 2.5 days) and in the postwithdrawal period (9.0±8.2
versus 14.6± 10. P<O.Ol. 95% CI = I .8- 9.4): and reported less withdrawal
severity. No severe adverse events reported.
Conclusions: Buprenorphine is effective for short-term ambulatory heroin
withdrawaI, with greater retention, less heroin use and less withdrawal discomfort during withdrawal: and increased postwithdrawal treatment retention than symptomatic medications.

The skeletal benefits of calcium- and vitamin D3-fortified milk are sustained in older men after withdrawal of supplementation: an 18 mo follow-up study

Background: In a previous 2-y randomized controlled trial, we showed that calcium- and vitamin D₃–fortified milk stopped or slowed bone loss at several clinically relevant skeletal sites in older men.

Objective: The present study aimed to determine whether the skeletal benefits of the fortified milk were sustained after withdrawal of the supplementation.

Design: One hundred nine men >50 y old who had completed a 2-y fortified milk trial were followed for an additional 18 mo, during which no fortified milk was provided. Bone mineral density (BMD) of the total hip, femoral neck, lumbar spine, and forearm was measured by using dual-energy X-ray absorptiometry.

Results: Comparison of the mean changes from baseline between the groups (adjusted for baseline age, BMD, total calcium intake, and change in weight) showed that the net beneficial effects of fortified milk on femoral neck and ultradistal radius BMD at the end of the intervention (1.8% and 1.5%, respectively; P < 0.01 for both) were sustained at 18-mo follow-up (P < 0.05 for both). The nonsignificant between-group differences at the total hip (0.8%; P = 0.17) also persisted at follow-up (0.7%; P = 0.10), but there were no lasting benefits at the lumbar spine. The average total dietary calcium intake in the milk supplementation group at follow-up approximated recommended amounts for Australian men >50 y old (1000 mg/d) but did not differ significantly from that in the control subjects (1021 versus 890 mg/d).

Conclusion: Supplementation with calcium- and vitamin D₃–fortified milk for 2 y may provide some sustained benefits for BMD in older men after withdrawal of supplementation.

Effect of naloxone-precipitated morphine withdrawal on c-fos expression in rat corticotropin-releasing hormone neurons in the paraventricular hypothalamus and extended amygdala

Morphine withdrawal is characterized by physical symptoms and a negative affective state. The 41 amino acid polypeptide corticotropin-releasing hormone (CRH) is hypothesized to mediate, in part, both the negative affective state and the physical withdrawal syndrome. Here, by means of dual-immunohistochemical methodology, we examined the co-expression of the c-Fos protein and CRH following naloxone-precipitated morphine withdrawal. Rats were treated with slow-release morphine 50 mg/kg (subcutaneous, s.c.) or vehicle every 48 h for 5 days, then withdrawn with naloxone 5 mg/kg (s.c.) or saline 48 h after the final morphine injection. Two hours after withdrawal rats were perfused transcardially and their brains were removed and processed for immunohistochemistry. We found that naloxone-precipitated withdrawal of morphine-dependent rats increased c-Fos immunoreactivity (IR) in CRH positive neurons in the paraventricular hypothalamus. Withdrawal of morphine-dependent rats also increased c-Fos-IR in the central amygdala and bed nucleus of the stria terminalis, however these were in CRH negative neurons.

Peripheral withdrawal recruits distinct central nuclei in morphine-dependent rats

This study examined if brain pathways in morphine-dependent rats are activated by opioid withdrawal precipitated outside the central nervous system. Withdrawal precipitated with a peripherally acting quaternary opioid antagonist (naloxone methiodide) increased Fos expression but caused a more restricted pattern of neuronal activation than systemic withdrawal (precipitated with naloxone which enters the brain). There was no effect on locus coeruleus and significantly smaller increases in Fos neurons were produced in most other areas. However in the ventrolateral medulla (A1/C1 catecholamine neurons), nucleus of the solitary tract (A2/C2 catecholamine neurons), lateral parabrachial nucleus, supramamillary nucleus, bed nucleus of the stria terminalis, accumbens core and medial prefrontal cortex no differences in the withdrawal treatments were detected. We have shown that peripheral opioid withdrawal can affect central nervous system pathways.

The politics of Australia's withdrawal from Iraq

This article examines the complex matrix of public, political and policy debates that were brought to bear on Australia's decision to withdraw from Iraq. In analysing the ‘politics of withdrawal’ in Australia, this article identifies four dominant frames that served to polarise the issue along party-political lines and reduce the complexities of Australia's withdrawal to a set of simple polarities (such as ‘stay the course’ versus ‘responsible withdrawal’). Specifically, these frames obfuscated an assessment of the myriad challenges facing post-Saddam Iraq and the prospects for peace, security and development beyond Australia's withdrawal. Understanding the ways in which Australia framed its decision to disengage from Iraq is critical to further analysis of Australia's approach to current (or future) military draw-downs (such as in Afghanistan), as well as those conducted by other liberal democracies, such as the US and the UK.

Introduction : The Iraq legacies: intervention, occupation, withdrawal and beyond

This chapter examines the various and complex legacies of the Iraq War of 2003. In follows the trajectory of these legacies back to the earliest days of the US intervention and examines the extent to which key decisions and errors of judgement on the part ofthe Coalition and the Iraqi political elite have had unexpected and devastating consequences for Iraq today. The chapter documents how the war dramatically altered the lives of ordinary Iraqis and led to many of the most deep-seated and intractable problems facing Iraq, the region and the world today. In discussing these legacies, this chapter also points to the root causes of the rapid turn of events that transpired after the dramatic advance of ISIS in mid-2014. The argument here being that the Iraq War of 2003 has left behind a sequence of deeply felt but rarely examined legacies and that together these legacies have served as the catalyst of Iraq’s current chaos. Therefore, this chapter is not only timely, but it also addresses a significant lacuna in academic and policy debates by addressing a series of urgent questions concerning the legacies of Iraq.

The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect, and smoking behaviour: systematic review update and meta-analysis

RATIONALE: Smoking cessation is associated with cigarette cravings and tobacco withdrawal symptoms (TWS), and exercise appears to ameliorate many of these negative effects. A number of studies have examined the relationships between exercise, cigarette cravings, and TWS. OBJECTIVES: The objectives of this study were (a) to review and update the literature examining the effects of short bouts of exercise on cigarette cravings, TWS, affect, and smoking behaviour and (b) to conduct meta-analyses of the effect of exercise on cigarette cravings. METHODS: A systematic review of all studies published between January 2006 and June 2011 was conducted. RESULTS: Fifteen new studies were identified, 12 of which found a positive effect of exercise on cigarette cravings. The magnitude of statistically significant effect sizes for 'desire to smoke' and 'strength of desire to smoke' ranged from 0.4 to 1.98 in favour of exercise compared to passive control conditions, and peaked either during or soon after treatment. Effects were found up to 30 min post-exercise. Cigarette cravings were reduced following exercise with a wide range of intensities from isometric exercise and yoga to activity as high as 80-85 % heart rate reserve. Meta-analyses revealed weighted mean differences of -1.90 and -2.41 in 'desire to smoke' and 'strength of desire to smoke' outcomes, respectively. Measures of TWS and negative affect were reduced following light-moderate intensity exercise, but increased during vigorous exercise. CONCLUSIONS: Exercise can have a positive effect on cigarette cravings and TWS. However, the most effective exercise intensity to reduce cravings and the underlying mechanisms associated with this effect remain unclear.

An integrative review of how families are prepared for, and supported during withdrawal of life-sustaining treatment in intensive care

AIM: To conduct an integrative review on how nurses prepare families for and support families during withdrawal of life-sustaining treatments in intensive care.

BACKGROUND: End-of-life care is widely acknowledged as integral to the practice of intensive care. However, little is known about what happens after the decision to withdraw life-sustaining treatments has been made and how families are prepared for death and the dying process.

DESIGN: Integrative literature review.

DATA SOURCES: MEDLINE, CINAHL Plus, PsychINFO, PUBMED, Scopus, EMBASE and Web of Knowledge were searched for papers published between 2000 - May 2015.

REVIEW METHODS: A five stage review process, informed by Whittemore and Knafl's methodology was conducted. All papers were reviewed and quality assessment performed. Data were extracted, organised and analysed. Convergent qualitative thematic synthesis was used.

RESULTS: From an identified 479 papers, 24 papers were included in this review with a range of research approaches: qualitative (n=15); quantitative (n=4); mixed methods (n=2); case study (n=2); and discourse analysis (n=1). Thematic analysis revealed the nurses: equipped families for end of life through information provision and communication; managed the withdrawal of life-sustaining treatments to meet family need; and continued care to build memories.

CONCLUSION: Greater understanding is needed of the language that can be used with families to describe death and dying in intensive care. Clearer conceptualisation of the relationship between the medically focussed withdrawal of life-sustaining treatments and patient/family centred end-of-life care is required making the nursing contribution at this time more visible.

Family centred care before and during life-sustaining treatment withdrawal in intensive care: a survey of information provided to families by Australasian critical care nurses

BACKGROUND: A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances.

OBJECTIVE: To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment.

DESIGN: An online cross-sectional survey.

METHODS: During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data.

RESULTS: From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided.

CONCLUSIONS: The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time.

Gay men's estimates of the likelihood of HIV transmission in sexual behaviours

In 3 studies we recorded gay men's estimates of the likelihood that HIV would be transmitted in various sexual behaviours. In Study 1 (data collected 1993, n=92), the men were found to believe that transmissibility is very much greater than it actually is; that insertive unprotected anal intercourse (UAI) by an HIV-infected partner is made safer by withdrawal before ejaculation, and very much safer by withdrawal before either ejaculation or pre-ejaculation; that UAI is very much safer when an infected partner is receptive rather than insertive; that insertive oral sex by an infected partner is much less risky than even the safest variant of UAI; that HIV is less transmissible very early after infection than later on; and that risk accumulates over repeated acts of UAI less than it actually does. In Study 2 (data collected 1997/8, n=200), it was found that younger and older uninfected men generally gave similar estimates of transmissibility, but that infected men gave somewhat lower estimates than uninfected men; and that estimates were unaffected by asking the men to imagine that they themselves, rather than a hypothetical other gay man, were engaging in the behaviours. Comparison of the 1993 and 1997/8 results suggested that there had been some effect of an educational campaign warning of the dangers of withdrawal; however, there had been no effect either of a campaign warning of the dangers of receptive UAI by an infected partner, or of publicity given to the greater transmissibility of HIV shortly after infection. In Study 3 (data collected 1999, n=59), men induced into a positive mood were found to give lower estimates of transmissibility than either men induced into a neutral mood or men induced into a negative mood. It is argued that the results reveal the important contribution made to gay men's transmissibility estimates by cognitive strategies (such as the 'availability heuristic' and 'anchoring and adjustment') known to be general characteristics of human information-processing. Implications of the findings for AIDS education are discussed.

On- and off-campus student persistence and academic performance

A study of more than 9000 unit enrolments in an Australian engineering programme found that: (a) the off-campus withdrawal rate was close to twice that for on-campus students; (b) whether a student withdrew or not was highly correlated to their mode of study; (c) the rate of withdrawal was significantly different between the two student groups; (d) the grade distribution for completing students was significantly different between the two groups; (e) the mean final grade was significantly higher for off-campus students; (f) the failure rate for off-campus students was significantly lower; and (g) the overall wastage rate (withdrawn rate plus fail rate) was significantly higher for off-campus students