Housing insecurity among black women surviving intimate partner violence during the COVID-19 pandemic: an intersectional qualitative approach

BACKGROUND

Housing instability is highly prevalent among intimate partner violence (IPV) survivors, and the coupling consequences of structural racism, sexism, classism, and the COVID-19 pandemic, may create more barriers to safe and adequate housing, specifically for Black women IPV survivors. In particular, the consequences of the COVID-19 pandemic had the potential to amplify disadvantages for Black women IPV survivors, yet very little research has acknowledged it. Therefore, the current study sought to assess the experiences of housing insecurity among Black women experiencing intimate partner violence (IPV) while navigating racism, sexism, and classism during the COVID-19 pandemic.

METHODS

From January to April 2021, we conducted in-depth interviews with 50 Black women experiencing IPV in the United States. Guided by intersectionality, a hybrid thematic and interpretive phenomenological analytic approach was used to identify sociostructural factors shaping housing insecurity.

RESULTS

Our findings demonstrate the various ways in which the COVID-19 pandemic shaped Black women IPV survivors' ability to obtain and sustain safe housing. We derived five themes to capture factors contributing to housing experiences: challenges with separate and unequal neighborhoods; pandemic-related economic inequalities; economic abuse limitations; and strategies to maintain housing.

CONCLUSIONS

Obtaining and maintaining safe housing during the COVID-19 pandemic was difficult for Black women IPV survivors who were also navigating racism, sexism, and socioeconomic position. Interventions are needed to reduce the impact of these intersecting systems of oppression and power to facilitate the resources necessary for Black women IPV survivors to identify safe housing.

Persistent Dissociation and Its Neural Correlates in Predicting Outcomes After Trauma Exposure

OBJECTIVE

Dissociation, a disruption or discontinuity in psychological functioning, is often linked with worse psychiatric symptoms; however, the prognostic value of dissociation after trauma is inconsistent. Determining whether trauma-related dissociation is uniquely predictive of later outcomes would enable early identification of at-risk trauma populations. The authors conducted the largest prospective longitudinal biomarker study of persistent dissociation to date to determine its predictive capacity for adverse psychiatric outcomes following acute trauma.

METHODS

All data were part of the Freeze 2 data release from the Advancing Understanding of Recovery After Trauma (AURORA) study. Study participants provided self-report data about persistent derealization (N=1,464), a severe type of dissociation, and completed a functional MRI emotion reactivity task and resting-state scan 2 weeks posttrauma (N=145). Three-month follow-up reports were collected of posttraumatic stress, depression, pain, anxiety symptoms, and functional impairment.

RESULTS

Derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activation in the emotion reactivity task and decreased resting-state vmPFC connectivity with the cerebellum and orbitofrontal cortex. In separate analyses, brain-based and self-report measures of persistent derealization at 2 weeks predicted worse 3-month posttraumatic stress symptoms, distinct from the effects of childhood maltreatment history and current posttraumatic stress symptoms.

CONCLUSIONS

The findings suggest that persistent derealization is both an early psychological and biological marker of worse later psychiatric outcomes. The neural correlates of trauma-related dissociation may serve as potential targets for treatment engagement to prevent posttraumatic stress disorder. These results underscore dissociation assessment as crucial following trauma exposure to identify at-risk individuals, and they highlight an unmet clinical need for tailored early interventions.

A prospective examination of sex differences in posttraumatic autonomic functioning

BACKGROUND

Cross-sectional studies have found that individuals with posttraumatic stress disorder (PTSD) exhibit deficits in autonomic functioning. While PTSD rates are twice as high in women compared to men, sex differences in autonomic functioning are relatively unknown among trauma-exposed populations. The current study used a prospective design to examine sex differences in posttraumatic autonomic functioning.

METHODS

192 participants were recruited from emergency departments following trauma exposure (Mean age = 35.88, 68.2% female). Skin conductance was measured in the emergency department; fear conditioning was completed two weeks later and included measures of blood pressure (BP), heart rate (HR), and high frequency heart rate variability (HF-HRV). PTSD symptoms were assessed 8 weeks after trauma.

RESULTS

2-week systolic BP was significantly higher in men, while 2-week HR was significantly higher in women, and a sex by PTSD interaction suggested that women who developed PTSD demonstrated the highest HR levels. Two-week HF-HRV was significantly lower in women, and a sex by PTSD interaction suggested that women with PTSD demonstrated the lowest HF-HRV levels. Skin conductance response in the emergency department was associated with 2-week HR and HF-HRV only among women who developed PTSD.

CONCLUSIONS

Our results indicate that there are notable sex differences in autonomic functioning among trauma-exposed individuals. Differences in sympathetic biomarkers (BP and HR) may have implications for cardiovascular disease risk given that sympathetic arousal is a mechanism implicated in this risk among PTSD populations. Future research examining differential pathways between PTSD and cardiovascular risk among men versus women is warranted.

Neurophysiological responses to safety signals and the role of cardiac vagal control

BACKGROUND

Deficits in safety signal learning are well-established in fear-related disorders (e.g., PTSD, phobias). The current study used a fear conditioning paradigm to test associations among eye blink startle and event-related brain potential (ERP) latency measures of safety signal learning, as well as the role of cardiac vagal control (a measure of top-down inhibition necessary for safety learning).

METHODS

Participants were 49 trauma-exposed women ages 17 to 28 years. Eyeblink startle response and ERP amplitudes/latencies were derived for conditioned stimuli associated (CS+) and not associated (CS-) with an aversive unconditioned stimulus. ERPs included the P100 and late positive potential (LPP), which index early visual processing and sustained emotional encoding, respectively. Cardiac vagal control was assessed with resting heart rate variability (HRV).

RESULTS

P100 and LPP latencies for the CS- (safety signal stimulus) were significantly negatively associated with startle to the CS-, but not the CS + . LPP CS- latencies were significantly negatively associated with PTSD Intrusion scores, and this relationship was moderated by vagal control, such that the effect was only present among those with low HRV.

CONCLUSIONS

ERP-based markers of safety signal learning were associated with startle response to the CS- (but not CS+) and PTSD symptoms, indicating that these markers may have relevance for fear-related disorders. Cardiac vagal control indexed by HRV is a moderating factor in these associations and may be relevant to safety signal learning.

Consumer and clinician perspectives on personalising breast cancer prevention information

BACKGROUND

Personalised prevention of breast cancer has focused on women at very high risk, yet most breast cancers occur in women at average, or moderately increased risk (≤moderate risk).

OBJECTIVES

To determine; 1) interest of women at ≤ moderate risk (consumers) in personalised information about breast cancer risk; 2) familial cancer clinicians' (FCCs) perspective on managing women at ≤ moderate risk, and; 3) both consumers' and FCCs reactions to iPrevent, a personalised breast cancer risk assessment and risk management decision support tool.

METHODS

Seven focus groups on breast cancer risk were conducted with 49 participants; 27 consumers and 22 FCCs. Data were analysed thematically.

RESULTS

Consumers reported some misconceptions, low trust in primary care practitioners for breast cancer prevention advice and frustration that they often lacked tailored advice about breast cancer risk. They expressed interest in receiving personalised risk information using iPrevent. FCCs reported an inadequate workforce to advise women at ≤ moderate risk and reacted positively to the potential of iPrevent to assist.

CONCLUSIONS

While highlighting a potential role for iPrevent, several outstanding issues remain. For personalised prevention of breast cancer to extend beyond women at high risk, we must harness women's interest in receiving tailored information about breast cancer prevention and identify a workforce willing to advise women.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

OBJECTIVE

Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).

METHODS

The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data.

RESULTS

Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.

CONCLUSION

The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.

PRACTICE IMPLICATIONS

Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

Abstract P6-09-04: Benign breast disease and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC)

Background: Benign breast disease (BBD) is one of the strongest risk factors for breast cancer but it is unclear whether the strength of the association with BBD and breast cancers varies by breast cancer family history. Few studies of BBD enrich specifically for putative genetic factors by over-sampling based on family history let alone evaluate potential interactions with measures of underlying familial risk. The aim of this study was to evaluate how risk associated with BBD is modified by underlying familial risk so as to guide clinical management and risk assessment of women with BBD.

Methods: Using a prospective family study cohort of 17,154 women unaffected with breast cancer at baseline and followed by questionnaire at regular intervals, we examined the association between BBD and breast cancer risk using Cox Proportional Hazards models. We classified women as having BBD if they reported at baseline having been told by a doctor that they had BBD, such as a non-cancerous cyst or breast lump. We did not have information on histologic sub-type. We confirmed self-reported diagnosis of BBD with pathology reports in a subset of the New York cohort and found high agreement between self-reported and pathologically confirmed BBD (93.5%). We assessed multiplicative and additive interactions with underlying familial risk profile (FRP) defined as either fixed-time horizon of 1-year, or total lifetime risk, estimated from the Breast Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) model.

Results: During 176,756 person-years of follow-up (mean 10.2, maximum 23.7 years), we observed 968 incident breast cancers cases with an average age at diagnosis of 55.8 years and average age at enrollment into the cohort of 46.8 years. At baseline, 4,704 (27%) women reported having a previous diagnosis of BBD. Compared to women with no history of BBD, breast cancer risk was increased in women of all ages (HR: 1.37, 95% CI: 1.19,1.56), and in women up to age 45 years (using attained age models) (HR: 1.40, 95% CI: 1.01,1.93). In terms of recency of BBD, we found that the increased risk associated with BBD remained 21 years or more after the initial BBD diagnosis (HR: 1.37, 95% CI: 1.11, 1.68). We found no evidence for multiplicative interactions with FRP, which implies that the increase in absolute risk associated with BBD depends on a woman's FRP (Table 1).

Conclusions: Women with a history of BBD have an increased risk of breast cancer that multiplies their underlying familial risk (FRP). These results could prove to be valuable for risk counseling and clinical management.

Table 1: Cumulative Incidence of Breast Cancer to age 45, 55, and 65 by BBD and underlying FRP as measured by 10-year BOADICEA score.AgeNo BBD, <3.4 %BBD, <3.4%No BBD, ≥3.4%BBD, ≥3.4%454.6 (3.8, 5.6)6.1(4.7, 8.0)12.1 (10.2, 14.5)16.1 (13.1, 19.7)557.4 (6.3, 8.7)9.8 (7.5, 12.8)19.1 (16.6, 22.0)25.0 (21.7, 28.9)659.7 (8.2, 11.5)12.8 (9.9, 16.5)24.5 (21.8, 27.6)31.8 (28.3, 35.7)

Citation Format: Zeinomar N, Phillips KA, Liao Y, MacInnis RJ, Dite GS, Daly MB, John EM, Andrulis IL, Buys SS, Hopper JL, Terry MB. Benign breast disease and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-04.

Abstract P6-09-01: Risk-reducing oophorectomy and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC)

Background: Whether risk-reducing salpingo oophorectomy (RRSO) reduces breast cancer risk in addition to reducing ovarian cancer risk is controversial with some arguing that the previous evidence of a reduction in breast cancer risk from RRSO was due to bias. Evidence from independent prospective cohorts of high-risk women is needed to resolve this controversy.

Methods: Using a prospective family study cohort of 17,810 women unaffected with breast cancer at baseline, we examined the association between RRSO and breast cancer risk using Cox Proportional Hazards models. We compared results estimating RRSO as a non-time-dependent variable to results treating RRSO as a time-dependent variable, because failing to account for the time-varying nature of a covariate person- time prior to RRSO, should it exist, will incorrectly attribute the cancer-free person-time to RRSO. We separately examined the association with RRSO in BRCA1 and BRCA2 mutation carriers and non-carriers, and further performed gene-stratified analyses in women with BRCA1 and BRCA2 only. We also assessed multiplicative interactions with underlying familial risk profile (FRP), defined as total lifetime risk estimated from the Breast Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) model.

Results: During a median 10.7 years of follow-up (maximum 23.7 years), we observed 1,040 incident cases of breast cancer with an average age at diagnosis of 55.8 years and average age at enrollment into the cohort of 46.8 years. A total of 2434 (14%) women reported at baseline having a RRSO. We observed decreased risk of breast cancer associated with RRSO for both BRCA1(N= 650) and BRCA2(N=557) mutation carriers when RRSO was treated as a fixed covariate (HR= 0.60, 95% CI=0.40-0.92 and HR= 0.40, 95%CI = 0.23-0.69, respectively). In contrast, when we treated RRSO as a time-varying covariate, for both BRCA1 and BRCA2 carriers, we no longer observed a decreased risk for BRCA1 and BRCA2 carriers (HR= 1.67, 95% CI=1.05-2.67 and HR= 0.97, 95%CI = 0.53-1.80, respectively). There was no association between RRSO and breast cancer risk for non-carriers (N=16,603), whether we treated RRSO as a fixed or time varying covariate (HR= 0.88, 95% CI=0.72-1.08 and HR= 1.06, 95%CI = 0.85-1.30, respectively).

Conclusions: Our findings provide an independent replication that the reduced risk of breast cancer previously observed in BRCA1 and BRCA2 mutation carrier women may be from bias in counting person-time. Clinical management of high-risk women should counsel based on the reduced risk of ovarian cancer from RRSO, but not breast cancer.

Citation Format: Terry MB, Phillips KA, Daly MB, Andrulis IL, Liao Y, Ma X, Zeinomar N, MacInnis RJ, Dite GS, John EM, Buys SS, Hopper JL. Risk-reducing oophorectomy and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-01.

A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder

BACKGROUND

This report prospectively examines the 4-year course, and predictors of course, of body dysmorphic disorder (BDD), a common and often severe disorder. No prior studies have prospectively examined the course of BDD in individuals ascertained for BDD. Method The Longitudinal Interval Follow-Up Evaluation (LIFE) assessed weekly BDD symptoms and treatment received over 4 years for 166 broadly ascertained adults and adolescents with current BDD at intake. Kaplan-Meier life tables were constructed for time to remission and relapse. Full remission was defined as minimal or no BDD symptoms, and partial remission as less than full DSM-IV criteria, for at least 8 consecutive weeks. Full relapse and partial relapse were defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining full or partial remission respectively. Cox proportional hazards regression examined predictors of remission and relapse.

RESULTS

Over 4 years, the cumulative probability was 0.20 for full remission and 0.55 for full or partial remission from BDD. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. Eighty-eight percent of subjects received mental health treatment during the follow-up period.

CONCLUSIONS

In this observational study, BDD tended to be chronic. Several intake variables predicted greater chronicity of BDD.

Adequacy of risk-reducing gynaecologic surgery in BRCA1 or BRCA2 mutation carriers and other women at high risk of pelvic serous cancer

The aim of this study was to describe the type of risk-reducing gynaecologic surgery (RRGS) and the extent of pathological evaluation being undertaken for Australasian women at high familial risk of pelvic serous cancer. Surgical and pathology reports were reviewed for women with BRCA1/BRCA2 mutations, or a family history of breast and ovarian cancer, who underwent RRGS between 1998 and 2008. "Adequate" surgery was defined as complete removal of all ovarian and extra-uterine fallopian tube tissue. "Adequate" pathology was defined as paraffin embedding of all removed ovarian and tubal tissue. Predictors of adequacy were assessed using logistic regression. There were 201 women, including 173 mutation carriers, who underwent RRGS. Of these, 91% had adequate surgery and 23% had adequate pathology. Independent predictors of adequate surgery were surgeon type (OR = 20; 95% CI 2-167; P = 0.005 for gynaecologic oncologists versus general gynaecologists), more recent surgery (OR = 1.33/year; 95% CI 1.07-1.67; P = 0.012) and younger patient age (OR = 0.93/year of age; 95% CI 0.87-0.99; P = 0.028). Independent predictors of adequate pathology were more recent surgery (OR = 1.26/year; 95% CI 1.06-1.49; P = 0.008) and surgeon type (OR = 3.1; 95% CI 1.4-6.7; P = 0.004 for gynaecologic oncologists versus general gynaecologists). Four serous ovarian cancers and one endometrioid endometrial cancer were detected during surgery or pathological examination. In conclusion Australasian women attending a specialist gynaecologic oncologist for RRGS are most likely to have adequate surgery and pathological examination. Additional education of clinicians and consumers is needed to ensure optimal surgery and pathology in these women.

Age-related differences in corpus callosum area of capuchin monkeys

Capuchin monkeys (Cebus apella) are New World primates with relatively large brains for their body size. The developmental trajectories of several brain regions-including cortical white matter, frontal lobe white matter, and basal ganglia nuclei-are similar to humans. Additionally, capuchins have independently evolved several behavioral and anatomical characteristics in common with humans and chimpanzees-including complex manipulative abilities, use of tools, and the use of precision grips-making them interesting species for studies of comparative brain morphology and organization. Here, we report the first investigation into the development of the corpus callosum (CC) and its regional subdivisions in capuchins. CC development was quantified using high-resolution structural magnetic resonance imaging (MRI) images from 39 socially reared subjects (male n=22; female n=18) ranging in age from 4 days (infancy) to 20 years (middle adulthood). The total area of the CC and the subdivisions of the genu, rostral midbody, medial midbody, caudal midbody, and splenium were traced from the midsagittal section. Total CC area displayed significant differences across this time span and was best explained by quadratic growth. Sustained linear growth was observed in the subdivisions of the genu, rostral midbody, and splenium; sustained quadratic growth was seen in the subdivision of the medial midbody. Differences in growth were not detected in the subdivision of the caudal midbody. Females had a larger raw area of the total CC and of the medial midbody and caudal midbody throughout the lifespan. Our results indicate that capuchins show continued white matter development beyond adolescence in regions related to cognitive and motor development.

Prospective study of breast cancer risk for mutation negative women from BRCA1 or BRCA2 mutation positive families

Published studies have reached contradictory conclusions regarding breast cancer risk for women from families segregating a BRCA1 or BRCA2 mutation who do not carry the family-specific mutation. Accurate estimation of breast cancer risk is crucial for appropriate counselling regarding risk management. The aim of this study is to prospectively assess whether breast cancer risk for mutation negative women from families segregating BRCA1 or BRCA2 mutations is greater than for women in the general population. Eligible women were 722 first-, second- and third-degree relatives of a BRCA1 or BRCA2 mutation carrier from 224 mutation positive (128 BRCA1, 96 BRCA2) families, had no personal cancer history at baseline, and had been tested and found not to carry the family-specific mutation. Self-reported family history of cancer, preventive interventions and verified cancer diagnoses were collected at baseline, and every 3 years thereafter. Median follow-up was 6.1 years (range 0.1-12.4 years). Time at risk of breast cancer was censored at cancer diagnosis or risk-reducing surgery. Standardised incidence ratios (SIR) were estimated by comparing observed to population incidences of invasive breast cancer using Australian Cancer Incidence and Mortality Books. Six cases of invasive breast cancer were observed. The estimated SIRs were 1.14 (95% CI: 0.51-2.53) overall (n = 722), 1.29 (95% CI: 0.58-2.88) when restricted to first- and second-degree relatives of an affected mutation carrier (n = 442) and 0.48 (95% CI: 0.12-1.93) when restricted to those with no family history of breast cancer in the non-mutation carrying parental lineage (n = 424). There was no evidence that mutation negative women from families segregating BRCA1 or BRCA2 mutations are at increased risk of breast cancer. Despite this being the largest prospective cohort to assess this issue, moderately increased breast cancer risk (2-fold) cannot be ruled out.

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Evolution of the cerebellar cortex: the selective expansion of prefrontal-projecting cerebellar lobules

It has been suggested that interconnected brain areas evolve in tandem because evolutionary pressures act on complete functional systems rather than on individual brain areas. The cerebellar cortex has reciprocal connections with both the prefrontal cortex and motor cortex, forming independent loops with each. Specifically, in capuchin monkeys cerebellar cortical lobules Crus I and Crus II connect with prefrontal cortex, whereas the primary motor cortex connects with cerebellar lobules V, VI, VIIb, and VIIIa. Comparisons of extant primate species suggest that the prefrontal cortex has expanded more than cortical motor areas in human evolution. Given the enlargement of the prefrontal cortex relative to motor cortex in humans, our hypothesis would predict corresponding volumetric increases in the parts of the cerebellum connected to the prefrontal cortex, relative to cerebellar lobules connected to the motor cortex. We tested the hypothesis by comparing the volumes of cerebellar lobules in structural MRI scans in capuchins, chimpanzees and humans. The fractions of cerebellar volume occupied by Crus I and Crus II were significantly larger in humans compared to chimpanzees and capuchins. Our results therefore support the hypothesis that in the cortico-cerebellar system, functionally related structures evolve in concert with each other. The evolutionary expansion of these prefrontal-projecting cerebellar territories might contribute to the evolution of the higher cognitive functions of humans.

Addressing the challenges of the clinical application of pharmacogenetic testing

Pharmacogenomics aims to use molecular genetic markers to predict treatment outcome. Indeed, within the past decade there has been a rapid emergence of pharmacogenetic tests to aid clinicians in predicting efficacy or toxicity for some drugs. Despite this major advance in therapeutic drug management, there remain challenges to the appropriate use of pharmacogenetic tests. We discuss UGT1A1 pharmacogenetic testing to illustrate the knowledge gaps impeding widespread use of pharmacogenetic tests in the clinical setting.

A comparative study of corpus callosum size and signal intensity in capuchin monkeys (Cebus apella) and chimpanzees (Pan troglodytes)

The evolution of corpus callosum (CC) was integral to the development of higher cognitive processes and hemispheric specialization. An examination of CC morphology and organization across different primate species will further our understanding of the evolution of these specified functions. Using magnetic resonance imaging (MRI) as a non-invasive technique to measure CC size and to approximate the degree of myelination in the corpus callosum, we report differences in CC morphology and organization in capuchin monkeys and chimpanzees, two divergent primate species that have independently evolved several behavioral and anatomical characteristics. Species differences in CC morphology were detected, with chimpanzees having a larger overall CC compared to capuchin monkeys. Additionally, chimpanzees had the genu as the largest subdivision; in capuchin monkeys, the genu and splenium were the largest subdivisions. Sex differences in signal intensity were detected; capuchin monkey males had higher signal intensity values whereas chimpanzee females had higher signal intensity values. Thus, while capuchin monkeys and chimpanzees show some similarity in patterns of CC morphology, these species differ significantly in the regional organization of the CC.

Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness

DSM-IV's classification of body dysmorphic disorder (BDD) is controversial. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a psychotic disorder. However, the relationship between these BDD variants has received little investigation. In this study, we compared BDD's delusional and nondelusional variants in 191 subjects using reliable and valid measures that assessed a variety of domains. Subjects with delusional BDD were similar to those with nondelusional BDD in terms of most variables, including most demographic features, BDD characteristics, most measures of functional impairment and quality of life, comorbidity, and family history. Delusional and nondelusional subjects also had a similar probability of remitting from BDD over 1 year of prospective follow-up. However, delusional subjects had significantly lower educational attainment, were more likely to have attempted suicide, had poorer social functioning on several measures, were more likely to have drug abuse or dependence, were less likely to currently be receiving mental health treatment, and had more severe BDD symptoms. However, when controlling for BDD symptom severity, the two groups differed only in terms of educational attainment. These findings indicate that BDD's delusional and nondelusional forms have many more similarities than differences, although on several measures delusional subjects evidenced greater morbidity, which appeared accounted for by their more severe BDD symptoms. Thus, these findings offer some support for the hypothesis that these two BDD variants may constitute the same disorder. Additional studies are needed to examine this issue, which may have relevance for other disorders with both delusional and nondelusional variants in DSM.

Fertility- and menopause-related information needs of younger women with a diagnosis of early breast cancer

PURPOSE

The use of chemotherapy and endocrine therapies in the treatment of premenopausal women carries with it reproductive and gynecologic implications that young women may find distressing and discordant with plans for childbearing. This multicenter study aimed to investigate fertility- and menopause-related information needs among young women with a diagnosis of early-stage breast cancer.

PATIENTS AND METHODS

Two hundred twenty-eight women with a diagnosis of early-stage breast cancer who were aged 40 years or younger at diagnosis and who were 6 to 60 months after diagnosis were entered onto the trial. Participants completed a mailed self-report questionnaire that included a purposely designed fertility- and menopause-related information needs survey and standardized measures of distress, anxiety, quality of life, menopausal symptoms, and information-seeking style.

RESULTS

Seventy-one percent of participants discussed fertility-related issues with a health professional as part of their breast cancer treatment, and 86% discussed menopause-related issues. Consultation with a fertility or menopause specialist was the most preferred method of obtaining this information. Receiving fertility-related information was rated as being significantly more important than receiving menopause-related information at time of diagnosis (P < .001) and at treatment decision making (P = .058). Receiving menopause-related information was rated as being significantly more important than receiving fertility-related information during adjuvant treatment (P < .05), at completion of adjuvant treatment (P < .001), and during follow-up (P < .001). Common questions, sources of information, and correlates of perceived importance were identified.

CONCLUSION

The results of this study suggest that younger women have unmet needs for fertility- and menopause-related information and provide preliminary empirical data to guide the development of better fertility- and menopause-related patient education materials for younger women with a diagnosis of early breast cancer.

Clinical, pathological and genetic features of women at high familial risk of breast cancer undergoing prophylactic mastectomy

Prophylactic mastectomy (PM) is a risk-management option for women at high familial risk of breast cancer (BC). This study describes the PM experience of women enrolled in a large observational cohort study involving families with a history of hereditary breast cancer. Within 357 multiple-case BC families [119 (33%) BRCA1 or BRCA2 mutation positive], identified via family cancer clinics, 49 cases of PM [21 (43%) BRCA1 or BRCA2 mutation positive] were identified and their clinical, pathological and genetic features reviewed. Families with at least one incidence of PM displayed stronger breast/ovarian cancer histories than did families without PM. Median age at time of PM was 45 years (range 28-58). Ten cases (21%) were bilateral PMs in unaffected women and 39 cases were contralateral PMs in women with prior invasive BC (71%) or ductal carcinoma in situ (DCIS) (8%). Most (88%) underwent total mastectomy. Unnecessary axillary surgery occurred in eight subjects (16%). Malignant histology was found in three PM specimens (6%). Prior to genetic testing, PM was performed in two women who were subsequently shown not to carry the mutation specific to their family. Optimal utilization of genetic testing to guide surgical decision making, appropriate surgical technique and careful pathology examination of PM specimens, are important issues to consider prior to PM in women at high familial risk of BC.

A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study

Population-based women (n=1049) with breast cancer diagnosed mainly between 1996 and 1998, when aged 20-59 years, were mailed a questionnaire seeking information about self-reported shoulder stiffness and swelling, numbness and pain/ache in the arm following treatment (excluding 6 months from diagnosis). Of the 809 who completed the survey, approximately seven in eight experienced at least one symptom, one in six reported all four symptoms, and one in three considered that their arm morbidity interfered substantially with activities of daily living. Arm swelling occurred at some time in 39% of women, was present in 20% 1 year, and in 29% 4 years, after diagnosis. The prevalence of arm swelling was higher in women with axillary node dissection (OR=2.4; 95% Cl 1.0-5.6), and was increased in a women with a higher body mass index (P=0.02) and less education (P=0.01), but was not related to age, number of nodes excised or self-reports of radiation or type of surgery.

Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review

CONTEXT

Adverse drug reactions are a significant cause of morbidity and mortality. Although many adverse drug reactions are considered nonpreventable, recent developments suggest these reactions may be avoided through individualization of drug therapies based on genetic information, an application known as pharmacogenomics.

OBJECTIVE

To evaluate the potential role of pharmacogenomics in reducing the incidence of adverse drug reactions.

DATA SOURCES

MEDLINE English-language only searches for adverse drug reaction studies published between January 1995 and June 2000 and review articles of variant alleles of drug-metabolizing enzymes published between January 1997 and August 2000. We also used online resources, texts, and expert opinion.

STUDY SELECTION

Detailed inclusion criteria were used to select studies. We included 18 of 333 adverse drug reaction studies and 22 of 61 variant allele review articles.

DATA EXTRACTION

All the investigators reviewed and coded articles using standardized abstracting forms.

DATA SYNTHESIS

We identified 27 drugs frequently cited in adverse drug reaction studies. Among these drugs, 59% are metabolized by at least 1 enzyme with a variant allele known to cause poor metabolism. Conversely, only 7% to 22% of randomly selected drugs are known to be metabolized by enzymes with this genetic variability (range, P =.006-P<.001).

CONCLUSIONS

Our results suggest that drug therapy based on individuals' genetic makeups may result in a clinically important reduction in adverse outcomes. Our findings serve as a foundation for further research on how pharmacogenomics can reduce the incidence of adverse reactions and on the resulting clinical, societal, and economic implications.

Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder

It appears that many individuals with body dysmorphic disorder (BDD) receive nonpsychiatric medical treatment and surgery; however, this topic has had little systematic investigation. This study assessed the nonpsychiatric treatment sought and received by 289 individuals (250 adults and 39 children/adolescents) with DSM-IV BDD. Such treatment was sought by 76.4% and received by 66.0% of adults. Dermatologic treatment was most often received (by 45.2% of adults), followed by surgery (by 23.2%). These treatments rarely improved BDD symptoms. Results were similar in children/adolescents. These findings indicate that a majority of patients with BDD receive nonpsychiatric treatment but tend to respond poorly.

Insight and treatment outcome in obsessive-compulsive disorder

To determine whether (1) insight in obsessive-compulsive disorder (OCD) improves when OCD symptoms improve, and whether (2) degree of insight in OCD predicts response to sertraline, data were obtained from five sites participating in a larger multisite study of relapse in OCD. During the first 16 weeks of the study, 71 patients received open-label treatment with sertraline and were assessed using the Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) and a rating scale to evaluate insight, the Brown Assessment of Beliefs Scale (BABS), at study baseline and termination. Baseline total BABS score was not significantly correlated with change in Y-BOCS score. Change in BABS total score and change in Y-BOCS total score were significantly correlated. There was no significant difference in mean endpoint Y-BOCS scores for patients with poor insight (n = 14) compared to patients with good insight at baseline (n = 57). Thus, insight improved with decrease in OCD symptom severity. Degree of insight at baseline did not predict response to sertraline, i.e., patients with poor insight were just as likely to respond to sertraline as patients with good insight.

The effect of risk factor reductions between 1981 and 1990 on coronary heart disease incidence, prevalence, mortality and cost

OBJECTIVES

We sought to estimate the impact and cost-effectiveness of risk factor reductions between 1981 and 1990.

BACKGROUND

Coronary heart disease (CHD) mortality rates have declined dramatically, partly as a result of reductions in CHD risk factors.

METHODS

We used the CHD Policy Model, a validated computer-simulation model, to estimate the effects of actual investments made to change coronary risk factors between 1981 and 1990, as well as the impact of these changes on the incidence, prevalence, mortality and costs of CHD during this period and projected to 2015.

RESULTS

Observed changes in risk factors between 1981 and 1990 resulted in a reduction of CHD deaths by approximately 430,000 and overall deaths by approximately 740,000, with an estimated cost-effectiveness of about $44,000 per year of life saved during this period, based on the estimated actual costs of the interventions used. However, because much of the benefit of risk factor reductions is delayed, the estimated reductions for the 35-year period of 1981 to 2015 were 3.6 million CHD deaths and 1.2 million non-CHD deaths, at a cost of only about $5,400 per year of life saved.

CONCLUSIONS

Aggregate efforts to reduce risk factors between 1981 and 1990 have led to substantial reductions in CHD and should be well worth the cost, largely because of population-wide changes in life-style and habits. Some interventions are much better investments than others, and attention to such issues could lead to better use of resources and better outcomes in the future.

A case of early-stage epithelial ovarian cancer in pregnancy

There are few reports in the literature of platinum-based chemotherapy administered in pregnancy. We present a case of serous adenocarcinoma of the ovary complicating pregnancy. Following laparotomy at 16 weeks of gestation, four cycles of cisplatin were administered prior to confinement at 32 weeks. There were no neonatal sequelae. We believe there is increasing evidence for the safe use of cisplatin in pregnancy.

Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study

BACKGROUND

Research on the pharmacotherapy of body dysmorphic disorder (BDD) is limited. No placebo-controlled, continuation, maintenance, or discontinuation studies have been published. Only one augmentation study has been published.

METHOD

In this chart-review study of 90 patients with DSM-IV BDD treated for up to 8 years by the first 2 authors (K.A.P., R.S.A.) in their clinical practice, response to a variety of medications, including augmentation strategies, was assessed. The relapse rate with medication discontinuation was also determined.

RESULTS

All subjects received a serotonin reuptake inhibitor (SRI), with 63.2% (55/87) of adequate SRI trials resulting in improvement in BDD symptoms; similar response rates were obtained for each type of SRI. Discontinuation of an effective SRI resulted in relapse in 83.8% (31/37) of cases. Response rates to selective SRI augmentation were clomipramine, 44.4% (4/9) of trials; buspirone, 33.3% (12/36) of trials; lithium, 20.0% (1/5); methylphenidate, 16.7% (1/6); and antipsychotics, 15.4% (2/13) of trials.

CONCLUSION

These findings from a clinical setting suggest that a majority of BDD patients improve with an SRI and that all SRIs appear effective. Certain SRI augmentation strategies may be beneficial. The high relapse rate with SRI discontinuation suggests that long-term treatment is often necessary. These preliminary findings require confirmation in placebo-controlled efficacy studies and effectiveness studies.

Current perspectives on BRCA1- and BRCA2-associated breast cancers

The identification of two breast cancer predisposition genes, BRCA1 and BRCA2, in the mid-1990s has led to a better understanding of the molecular pathogenesis of hereditary breast cancer and to a new era in breast cancer research. The present article reviews the current state of knowledge regarding the biology of BRCA1 and BRCA2, the cancer risks associated with carrying a pathogenic mutation in either of these genes and the possible genetic and environmental risk modifiers. The phenotypes of BRCA1- and BRCA2-associated hereditary breast cancers are reviewed. Research into BRCA1- and BRCA2-associated breast cancer is in its infancy and much remains to be learned, particularly about modifiers of genetic risk and the clinical implications of carrying a mutation in one of these two genes. Australia has an excellent research infrastructure in place, through the Australian Breast Cancer Family Study and the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer, to contribute substantially to future research in this area.

Deciding where and how to be tested for HIV: what matters most?

This study examined preferences for specific types of HIV tests as well as for test attributes such as cost, counseling, and privacy. A survey was administered to 354 clients of public testing services. Nonparametric tests and logistic regression were used to compare test preferences and attribute ratings, and to assess differences by demographic and risk groups. Nearly two thirds of respondents chose a public clinic test as their first choice, whereas 24% chose a home self-test, 12% chose a test at a doctor's office, and 1% chose a home specimen-collection test. Three attributes (accuracy/timeliness, privacy of test disclosure, and linking of test results) were rated equally-and most-important. In-person counseling was endorsed as the fourth most important attribute. Availability of in-person counseling was the strongest predictor of "loyalty" to public clinic tests-a consistent preference for that type of test even when the other tests were offered as additional no-cost options. There was also substantial interest in home self-tests. The results suggest specific attributes of testing that may be particularly important to individuals from diverse demographic and risk backgrounds.

A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice

BACKGROUND

Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting.

OBJECTIVE

To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings.

METHODS

A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50).

RESULTS

The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88.

CONCLUSIONS

This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

CONTEXT

Atrial fibrillation is the most common arrhythmia in elderly persons and a potent risk factor for stroke. However, recent prevalence and projected future numbers of persons with atrial fibrillation are not well described.

OBJECTIVE

To estimate prevalence of atrial fibrillation and US national projections of the numbers of persons with atrial fibrillation through the year 2050.

DESIGN, SETTING, AND PATIENTS

Cross-sectional study of adults aged 20 years or older who were enrolled in a large health maintenance organization in California and who had atrial fibrillation diagnosed between July 1, 1996, and December 31, 1997.

MAIN OUTCOME MEASURES

Prevalence of atrial fibrillation in the study population of 1.89 million; projected number of persons in the United States with atrial fibrillation between 1995-2050.

RESULTS

A total of 17 974 adults with diagnosed atrial fibrillation were identified during the study period; 45% were aged 75 years or older. The prevalence of atrial fibrillation was 0.95% (95% confidence interval, 0.94%-0.96%). Atrial fibrillation was more common in men than in women (1.1% vs 0.8%; P<.001). Prevalence increased from 0.1% among adults younger than 55 years to 9.0% in persons aged 80 years or older. Among persons aged 50 years or older, prevalence of atrial fibrillation was higher in whites than in blacks (2.2% vs 1.5%; P<.001). We estimate approximately 2.3 million US adults currently have atrial fibrillation. We project that this will increase to more than 5.6 million (lower bound, 5.0; upper bound, 6.3) by the year 2050, with more than 50% of affected individuals aged 80 years or older.

CONCLUSIONS

Our study confirms that atrial fibrillation is common among older adults and provides a contemporary basis for estimates of prevalence in the United States. The number of patients with atrial fibrillation is likely to increase 2.5-fold during the next 50 years, reflecting the growing proportion of elderly individuals. Coordinated efforts are needed to face the increasing challenge of optimal stroke prevention and rhythm management in patients with atrial fibrillation.

An online educational facility for medical oncology trainees: www.vmotg.org

PURPOSE

To design, implement, and evaluate a comprehensive educational Web site for medical oncology trainees.

METHODS

The Web site was designed with three main areas (termed Journal Club, Key Papers, and Oncology Links) and compiled from articles presented at the Victorian Medical Oncology Trainees' Group journal club from the preceding 3 years. The Key Papers section was then reviewed by 30 academic medical oncologists. The site was advertised by mail and at the Annual Meeting of the Medical Oncology Group of Australia. Evaluation was by mail survey.

RESULTS

The Web site, which may be accessed at www.vmotg.org, comprises more than 170 pages and 30,000 words of text. Journal club sessions are summarized with presented articles linked to abstracts from PubMed. Key Papers lists from five to 25 pivotal articles in each of 35 categories. Oncology Links is an extensive list of links in 10 categories including organizations, journals, and practice guidelines. Twenty-six of 45 trainees and 82 of 190 oncologists responded to the survey. Eighty-one percent of these trainees and 28% of oncologists have used the Web site. Ninety-six percent consider the Web site easy to use and "a useful medical oncology resource." All trainees rated the site good to excellent in terms of relevance and 94% considered the site beneficial to their education.

CONCLUSION

The Web site www.vmotg.org is a relevant and useful educational resource for Australian medical oncology trainees and oncologists. As far as the authors are aware, this is the only educational site specifically for medical oncology trainees throughout the world. It may be a valuable oncology education resource for trainees in other countries, particularly those in isolated areas.

Breast conservation in BRCA1 or BRCA2 mutation carriers with early stage breast cancer

The role of breast conservation therapy (limited surgery and irradiation of the breast with/without axilla) in the approximately 5% of breast cancer patients who harbour a germline mutation in BRCA1 or BRCA2, is a largely unexplored area and is seen by some as controversial. The relatively high cumulative risk of second primary cancers in such patients and concern about a possible decreased ability of mutation carriers to repair DNA damage caused by radiation has fuelled this controversy. Published studies of breast conservation therapy in carriers of a mutation in BRCA1 or BRCA2 are reviewed, with particular attention to their methodology. These studies have not demonstrated any increase in radiation sensitivity of normal tissues in mutation carriers, either in terms of increased early or late toxicity or tumourigenesis. Likewise, tumour sensitivity to radiotherapy, which might be expected based on the known functions of the BRCA1 and BRCA2 genes, has not been documented to date in mutation carriers. Further, methodologically rigorous studies of large numbers of breast cancer patients who carry a mutation in BRCA1 or BRCA2 are required to fully elucidate these issues.

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.

Kleptomania, compulsive buying, and binge-eating disorder

Although recognized since at least the early 19th century, kleptomania, compulsive buying, and binge-eating disorder are poorly understood conditions that have received little systematic study. In this article, we review the available studies of these three conditions, which suggest that they are more common than realized, occur more frequently in women than in men, cause significant morbidity, are related to other psychiatric disorders (especially to one another, impulse control disorders, obsessive-compulsive disorder, and mood disorders), and often respond to available psychopharmacologic and psychological treatments. We hypothesize that these three conditions might best be viewed as impulse control disorders that belong to an extended family of compulsive-impulsive spectrum disorders. The compulsive-impulsive spectrum disorders may, in turn, belong to the larger family of affective spectrum disorder.

Body dysmorphic disorder: an obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both?

Over the past century, body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been hypothesized to be related to obsessive-compulsive disorder (OCD). More recently, BDD has also been hypothesized to be a form of affective spectrum disorder. Affective spectrum disorder refers to a family of disorders postulated to have a common pathophysiologic abnormality. This grouping of disorders has been identified on the basis of their response to pharmacologic treatments and is supported by comorbidity and family studies. Available data suggest that BDD should be considered a candidate form of affective spectrum disorder--a disorder that may eventually be demonstrated to belong to this family of disorders. Available data also strongly support the hypothesis that BDD is an obsessive-compulsive spectrum disorder. Because OCD itself has been hypothesized to be an affective spectrum disorder, BDD may be more narrowly conceptualized as an obsessive-compulsive spectrum disorder and more broadly as a candidate form of affective spectrum disorder.

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.

Health and economic benefits of increased beta-blocker use following myocardial infarction

CONTEXT

beta-blockers are underused in patients who have myocardial infarction (MI), despite the proven efficacy of these agents. New evidence indicates that beta-blockers can have benefit in patients with conditions that have been considered relative contraindications. Understanding the consequences of underuse of beta-blockers is important because of the implications for current policy debates over quality-of-care measures and Medicare prescription drug coverage.

OBJECTIVE

To examine the potential health and economic impact of increased use of beta-blockers in patients who have had MI.

DESIGN AND SETTING

We used the Coronary Heart Disease (CHD) Policy Model, a computer-simulation Markov model of CHD in the US population, to estimate the epidemiological impact and cost-effectiveness of increased beta-blocker use from current to target levels among survivors of MI aged 35 to 84 years. Simulations included 1 cohort of MI survivors in 2000 followed up for 20 years and 20 successive annual cohorts of all first-MI survivors in 2000-2020. Mortality and morbidity from CHD were derived from published meta-analyses and recent studies. This analysis used a societal perspective.

MAIN OUTCOME MEASURES

Prevented MIs, CHD mortality, life-years gained, and cost per quality-adjusted life-year (QALY) gained in 2000-2020.

RESULTS

Initiating beta-blocker use for all MI survivors except those with absolute contraindications in 2000 and continuing treatment for 20 years would result in 4300 fewer CHD deaths, 3500 MIs prevented, and 45,000 life-years gained compared with current use. The incremental cost per QALY gained would be $4500. If this increase in beta-blocker use were implemented in all first-MI survivors annually over 20 years, beta-blockers would save $18 million and result in 72,000 fewer CHD deaths, 62,000 MIs prevented, and 447,000 life-years gained. Sensitivity analyses demonstrated that the cost-effectiveness of beta-blocker therapy would always be less than $11,000 per QALY gained, even under unfavorable assumptions, and may even be cost saving. Restricting beta-blockers only to ideal patients (those without absolute or relative contraindications) would reduce the epidemiological impact of beta-blocker therapy by about 60%.

CONCLUSIONS

Our simulation indicates that increased use of beta-blockers after MI would lead to impressive gains in health and would be potentially cost saving. JAMA. 2000;284:2748-2754.

Implications of the genetics revolution for health services research: pharmacogenomics and improvements in drug therapy

OBJECTIVE

To review the societal and economic implications of the use of genetic information to individualize drug therapies. Although studies have begun to address the ethical issues raised by the use of genetic information , few have examined the implications of pharmacogenomics f rom the perspective of health services research.

PRINCIPAL FINDINGS

We propose a research agenda for health services research in three areas: (1) to evaluate the effectiveness and cost-effectiveness of pharmacogenomics; (2) to evaluate the effect of pharmacogenomics from the perspective of patients, providers, insurers, industry, and government ; and (3) to evaluate the ethical and societal implications of pharmacogenomics. Throughout the article we use the example of HIV genotyping as an illustration of how genetic technology is disseminated and used.

CONCLUSION

More research is needed on the societal and economic implications of pharmacogenomics to inform the clinical and policy decisions about its use that will be increasingly urgent in the future.

Immunophenotypic and pathologic differences between BRCA1 and BRCA2 hereditary breast cancers

Morphologically and clinically, breast cancer is a heterogeneous group of diseases. This heterogeneity may be a manifestation of differences in the molecular genetic events underlying distinct breast cancer pathogenesis pathways. Examination of hereditary breast cancers (HBC), which have in common an underlying germline mutation in BRCA1 or BRCA2, may provide further insight into this concept. Multiple studies have confirmed that BRCA1-associated HBC (BRCA1-HBC) generally exhibit a specific phenotype that is characterized by high tumor grade and estrogen receptor negativity. Conversely, discrepancies exist between the findings of studies that have examined BRCA2-HBC, and a specific phenotype has not been consistently described. The characteristic phenotype of BRCA1-associated tumors may prove a useful additional tool in selecting individuals with breast cancer who should be offered BRCA1 mutation testing, although further studies are required. Lastly, evidence is emerging to suggest that BRCA1 might be involved in the pathogenesis of a subgroup of non-HBC (by gene underexpression rather than mutation) and that these tumors may exhibit the same phenotype as their hereditary counterparts.

HIV-1 drug resistance genotyping. A review of clinical and economic issues

The development of mutations associated with resistance to antiretroviral therapy (ART) has been shown to be a major cause of treatment failure in patients infected with HIV-1. These resistance mutations can be assessed by a genotyping test that probes for specific mutations within the HIV genome or sequences specific genes, at a cost $US500/test (2000 prices). The stated goal of HIV-1 genotyping is to target HIV therapy effectively. This, as shown in the preliminary research, should result in better clinical outcomes and a lower incidence of virological failure and may be associated with lower costs of treatment. Failure of ART may result in an increase in costs of at least $US250 per patient per month, as assessed in 1 study, with costs rising further as patients experience multiple virological failures. Therefore, there is an economic as well as a therapeutic premium on the prevention of ART failure. The actual economic cost of genotyping has been preliminarily explored in the context of the antiretroVIRal ADAPTation (VIRADAPT) trial, which found no significant difference in the 1-year treatment cost of patients with and without genotyping. There is some evidence of cost neutrality or savings with genotypic testing but it needs to be further explored within the context of carefully framed prospective trials.

The cost-effectiveness of expanded HIV counselling and testing in primary care settings: a first look

OBJECTIVE

To estimate the cost-effectiveness of approaches to expanded HIV counselling and testing.

DESIGN

A cost-effectiveness analysis.

SETTING

Primary care practices in the USA.

PARTICIPANTS

New patient visits.

INTERVENTIONS

Two approaches were examined: (i) requesting all patients to complete an HIV-risk screening instrument, with counselling as well as testing offered only to patients disclosing risk factors ('risk histories' option); and (ii) routine offering of voluntary testing to all patients, with consent obtained but no pre-test counselling ('routine testing').

MAIN OUTCOME MEASURES

The primary outcome was the cost per infection identified. We also examined: (i) the costs and numbers of infections averted if individuals change their risk behaviours; and (ii) the additional years of life and quality-adjusted life years (QALY) gained as a result of earlier HIV testing and treatment for infected individuals.

RESULTS

Routine testing is the most cost-effective approach to identifying infected individuals at an incremental cost of US$4200 per infection identified. Although using risk histories is more costly and less effective than routine testing, it becomes similarly cost-effective using plausible ranges for sensitivity analyses. If at least 10% of HIV-positive individuals change their behavior, both routine testing and using risk histories would save money. If testing identifies infected individuals one year earlier than they otherwise would have been diagnosed, routine testing would cost US$22000 per QALY gained.

CONCLUSION

Routine testing is the most cost-effective approach to identifying new HIV infections. However, using risk histories may be similarly cost-effective under various assumptions. Both routine testing and using risk histories are more cost-effective than current practices.