Rotational phase transitions in antifluorite-type osmate and iridate compounds

We present temperature-dependent single-crystal diffraction results on seven antifluorite-typeA2MeX6compounds withMe= Os or Ir: K2OsCl6,A2OsBr6withA= K, Rb, Cs and NH4, and K2IrX6withX= Cl and Br. The structural transitions in this family arise fromMeX6octahedron rotations that generate a rich variety of symmetries depending on the rotation axis and stacking schemes. In order to search for local distortions in the high-symmetry phase we perform refinements of anharmonic atomic displacement parameters with comprehensive data sets. Even at temperatures close to the onset of structural distortions, these refinements only yield a small improvement indicating only small anharmonic effects. The phase transitions in these antifluorites are essentially of displacive character. However, some harmonic displacement parameters are very large reflecting soft phonon modes with the softening covering large parts of the Brillouin zone. The occurrence of the rotational transitions in the antifluorite-type family can be remarkably well analyzed in terms of a tolerance factor of ionic radii.

Buprenorphine/naloxone access for people with opioid use disorder in correctional facilities: taking steps to support knowledge translation

People with opioid use disorders are overrepresented in correctional facilities, and are at high risk of opioid overdose. Despite the fact that buprenorphine/naloxone is the first line treatment for people with opioid use disorder, there are often institutional, clinical, and logistical barriers to buprenorphine/naloxone initiation in correctional facilities. Guided by the knowledge-to-action framework, this knowledge translation project focused on synthesizing knowledge and developing a tool for buprenorphine/naloxone initiation that was tailored to correctional facilities, including jails. This information and tool can be used to support buprenorphine/naloxone access for people in correctional facilities, in parallel with other efforts to address barriers to treatment initiation in correctional facilities.

Rates of opioid agonist treatment prescribing in provincial prisons in Ontario, Canada, 2015-2018: a repeated cross-sectional analysis

OBJECTIVE

To describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.

DESIGN

We used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.

SETTING

Provincial prisons and general population in Ontario, Canada between 2015 and 2018.

PARTICIPANTS

Adults incarcerated in provincial prisons and people ages 15 years and older in Ontario.

MAIN OUTCOMES AND MEASURES

Opioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.

RESULTS

In prison, 6.9%-8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.

CONCLUSIONS

The increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

The value of peer support for self-management of diabetes among veterans in the Empowering Patients In Chronic care intervention

AIM

To examine the value of peer support in the self-management of diabetes among veterans in an integrated health care system.

METHODS

We conducted semi-structured in-depth interviews with veterans and clinicians 6 months after their participation in Empowering Patients in Chronic Care (EPIC), a group-based diabetes intervention with a peer-support component. Interviews elicited clinicians' narratives of how peer support unfolded in the groups and veterans' experiences of giving and receiving support from their peers. Data analysis was guided by principles of framework analysis using Heisler's peer-support model.

RESULTS

Findings support Heisler's peer-support model and provide evidence supporting professional-led group visits with peer exchange. Clinicians and veterans endorsed informational and emotional support received in EPIC groups. Clinicians often referred to EPIC as an open forum or a support group where veterans could both give and receive help. Veterans noted the benefits of shared problem-solving and the support they received. Clinicians and veterans perceived the peer-support component of EPIC as facilitating increased empowerment in terms of self-efficacy, increased perceived social support and increased understanding of self-care. Ultimately, many veterans acknowledged that their participation in EPIC facilitated improved health-related quality of life, improved health behaviours and improved chronic disease control.

CONCLUSIONS

Findings emphasize the value of peer support in managing chronic illness. Peer-support programmes may address veterans' unique challenges and have the potential to improve physical and mental health.

90-90-90 for everyone?: Access to HIV care and treatment for people with HIV who experience imprisonment in Ontario, Canada

We examined HIV care and treatment in prison and after release for people with HIV in Ontario, Canada, and compared HIV care and treatment with the general population. We used administrative data to identify people with HIV released from provincial prison in 2010 and in the general population. We calculated the proportion of people with HIV who accessed HIV care in prison. We compared HIV care use between people with HIV on prison release and in the general population. We estimated the proportion of people with HIV on antiretroviral therapy in prison as the ratio of the average numbers of people prescribed antiretroviral therapy in prison in 2009/2010 and people with HIV in prison in January 2010. We compared the proportion of people with HIV on public drug benefits that filled an antiretroviral therapy prescription within 6 months for people postrelease and in the general population. Of 344 people with HIV on prison admission, 34.0% received HIV care in prison. Over 1 year, 63.6% of 330 people with HIV on prison release and 67.7% of 15,819 people with HIV in the general population accessed HIV care (p = 0.118), and 43.3% of people with HIV on prison release and 55.2% of people with HIV in the general population had 2 or more HIV care visits (p < 0.001). In prison, 52.4% of people with HIV (39.5/75.4) were on antiretroviral therapy. Of those accessing drug benefits, 60.1% of 226 people with HIV on prison release and 79.6% of 7458 people with HIV in the general population claimed an antiretroviral therapy prescription within 6 months (p < 0.001). Access to HIV care and treatment were suboptimal in prison, and sustained HIV care and treatment were worse for people post-release compared to the general population. Interventions are needed to support HIV care for this population.

Correction to: A comparison of the observed and expected prevalence of HIV in persons released from Ontario provincial prisons in 2010

The Acknowledgements section was inadvertently omitted from this article; it appears in its entirety below.

A comparison of the observed and expected prevalence of HIV in persons released from Ontario provincial prisons in 2010

OBJECTIVE

To estimate the prevalence of HIV infection in persons released from Ontario prisons in 2010 using administrative health data, and to compare this observed prevalence with the expected prevalence based on the most recently available biological sampling data.

METHODS

We linked identifying data for all adults released from Ontario provincial prisons in 2010 with administrative health data, and applied a validated algorithm to determine the observed HIV prevalence. We calculated the expected HIV prevalence using 2003-2004 age stratum-specific data from a published study using salivary sampling. We calculated an indirect standardized prevalence ratio of the observed to expected prevalence and 95% confidence intervals. Finally, we conducted sensitivity analyses to adjust for the sensitivity of the algorithm to identify persons with HIV and for undiagnosed HIV infection.

RESULTS

Of 52,313 persons released from Ontario prisons in 2010, we identified 363 persons with HIV, for an observed prevalence of 0.69%. The expected prevalence was 2.38%. Standardized for age, we found a prevalence ratio of 0.29 (95% CI, 0.17-0.77). Sensitivity analyses adjusting for the algorithm's sensitivity and further adjusting for undiagnosed HIV infection produced standardized prevalence ratios of 0.30 and 0.38, respectively.

CONCLUSION

Our findings suggest that a high proportion of persons with HIV recently released from provincial prisons either do not know they have HIV infection or do know about their infection but are not engaged in care. Interventions are required to screen people for HIV in prison and to link persons with care following release.

The health care utilization of people in prison and after prison release: A population-based cohort study in Ontario, Canada

BACKGROUND

Many people experience imprisonment each year, and this population bears a disproportionate burden of morbidity and mortality. States have an obligation to provide equitable health care in prison and to attend to care on release. Our objective was to describe health care utilization in prison and post-release for persons released from provincial prison in Ontario, Canada in 2010, and to compare health care utilization with the general population.

METHODS

We conducted a population-based retrospective cohort study. We included all persons released from provincial prison to the community in 2010, and age- and sex-matched general population controls. We linked identities for persons released from prison to administrative health data. We matched each person by age and sex with four general population controls. We examined ambulatory care and emergency department utilization and medical-surgical and psychiatric hospitalization, both in prison and in the three months after release to the community. We compared rates with those of the general population.

RESULTS

The rates of all types of health care utilization were significantly higher in prison and on release for people released from prison (N = 48,861) compared to general population controls (N = 195,444). Comparing those released from prison to general population controls in prison and in the 3 months after release, respectively, utilization rates were 5.3 (95% CI 5.2, 5.4) and 2.4 (95% CI 2.4, 2.5) for ambulatory care, 3.5 (95% CI 3.3, 3.7) and 5.0 (95% CI 4.9, 5.3) for emergency department utilization, 2.3 (95% CI 2.0, 2.7) and 3.2 (95% CI 2.9, 3.5) for medical-surgical hospitalization, and 21.5 (95% CI 16.7, 27.7) and 17.5 (14.4, 21.2) for psychiatric hospitalization. Comparing the time in prison to the week after release, ambulatory care use decreased from 16.0 (95% CI 15.9,16.1) to 10.7 (95% CI 10.5, 10.9) visits/person-year, emergency department use increased from 0.7 (95% CI 0.6, 0.7) to 2.6 (95% CI 2.5, 2.7) visits/person-year, and hospitalization increased from 5.4 (95% CI 4.8, 5.9) to 12.3 (95% CI 10.1, 14.6) admissions/100 person-years for medical-surgical reasons and from 8.6 (95% CI 7.9, 9.3) to 17.3 (95% CI 14.6, 20.0) admissions/100 person-years for psychiatric reasons.

CONCLUSIONS

Across care types, health care utilization in prison and on release is elevated for people who experience imprisonment in Ontario, Canada. This may reflect high morbidity and suboptimal access to quality health care. Future research should identify reasons for increased use and interventions to improve care.

Physician prescribing of opioid agonist treatments in provincial correctional facilities in Ontario, Canada: A survey

Background

Substance use and substance use disorders are common in people who experience detention or incarceration in Canada, and opioid agonist treatment (OAT) may reduce the harms associated with substance use disorders. We aimed to define current physician practice in provincial correctional facilities in Ontario with respect to prescribing OAT and to identify potential barriers and facilitators to prescribing OAT.

Methods

We invited all physicians practicing in the 26 provincial correctional facilities for adults in Ontario to participate in an online survey.

Results

Twenty-seven physicians participated, with representation from most correctional facilities in Ontario. Of participating physicians, 52% reported prescribing methadone and 48% reported prescribing buprenorphine/naloxone to patients in provincial correctional facilities. Nineteen percent of participants reported initiating methadone treatment and 11% reported initiating buprenorphine/naloxone for patients in custody. Participants identified multiple barriers to initiating OAT in provincial correctional facilities including concerns about medication diversion and safety, concerns about initiating treatment in patients who are not currently using opioids, lack of linkage with community-based providers and the Ministry of Community Safety and Correctional Services policy. Identified facilitators to initiating OAT were support from institutional health care staff and administrative staff, adequate resources for program delivery and access to linkage with community-based OAT providers.

Conclusions

This study identifies opportunities to improve OAT programs and to improve access to OAT for persons in provincial correctional facilities in Ontario.

Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study

BACKGROUND

We aimed to define rates and causes of death in custody and after release in people admitted to provincial custody in Ontario, and to compare these data with data for the general population.

METHODS

We linked data on adults admitted to provincial custody in Ontario in 2000 with data on deaths between 2000 and 2012. We examined rates and causes of death by age, sex, custodial status and period after release, and compared them with data for the general population, using indirect adjustment for age.

RESULTS

Between 2000 and 2012, 8.6% (95% confidence interval [CI] 8.3%-8.8%) of those incarcerated died in provincial custody or after release. The crude death rate was 7.1 (95% CI 6.9-7.3) per 1000 person-years. The standardized mortality ratio for those incarcerated in 2000 was 4.0 (95% CI 3.9-4.1) overall and 1.9 (95% CI 1.5-2.4) while in provincial custody. The most common causes of death were injury and poisoning (38.2% of all deaths), including overdose (13.6%) and suicide (8.2%), diseases of the circulatory system (15.8%) and neoplasms (14.5%). In the 2 weeks after release, the standardized mortality ratio was 5.7 overall and 56.0 for overdose. Life expectancy was 72.3 years for women and 73.4 for men who experienced incarceration in 2000.

INTERPRETATION

Mortality was high for people who experienced incarceration, and life expectancy was 4.2 years less for men and 10.6 years less for women compared with the general population. Efforts should be made to reduce the gap in mortality between people who experience incarceration and those who do not. Time in custody could serve as an opportunity to intervene to decrease risk.

Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study

BACKGROUND

We aimed to define rates and causes of death in custody and after release in people admitted to provincial custody in Ontario, and to compare these data with data for the general population.

METHODS

We linked data on adults admitted to provincial custody in Ontario in 2000 with data on deaths between 2000 and 2012. We examined rates and causes of death by age, sex, custodial status and period after release, and compared them with data for the general population, using indirect adjustment for age.

RESULTS

Between 2000 and 2012, 8.6% (95% confidence interval [CI] 8.3%-8.8%) of those incarcerated died in provincial custody or after release. The crude death rate was 7.1 (95% CI 6.9-7.3) per 1000 person-years. The standardized mortality ratio for those incarcerated in 2000 was 4.0 (95% CI 3.9-4.1) overall and 1.9 (95% CI 1.5-2.4) while in provincial custody. The most common causes of death were injury and poisoning (38.2% of all deaths), including overdose (13.6%) and suicide (8.2%), diseases of the circulatory system (15.8%) and neoplasms (14.5%). In the 2 weeks after release, the standardized mortality ratio was 5.7 overall and 56.0 for overdose. Life expectancy was 72.3 years for women and 73.4 for men who experienced incarceration in 2000.

INTERPRETATION

Mortality was high for people who experienced incarceration, and life expectancy was 4.2 years less for men and 10.6 years less for women compared with the general population. Efforts should be made to reduce the gap in mortality between people who experience incarceration and those who do not. Time in custody could serve as an opportunity to intervene to decrease risk.

Using a Delphi process to define priorities for prison health research in Canada

OBJECTIVES

A large number of Canadians spend time in correctional facilities each year, and they are likely to have poor health compared to the general population. Relatively little health research has been conducted in Canada with a focus on people who experience detention or incarceration. We aimed to conduct a Delphi process with key stakeholders to define priorities for research in prison health in Canada for the next 10 years.

SETTING

We conducted a Delphi process using an online survey with two rounds in 2014 and 2015.

PARTICIPANTS

We invited key stakeholders in prison health research in Canada to participate, which we defined as persons who had published research on prison health in Canada since 1994 and persons in the investigators' professional networks. We invited 143 persons to participate in the first round and 59 participated. We invited 137 persons to participate in the second round and 67 participated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants suggested topics in the first round, and these topics were collated by investigators. We measured the level of agreement among participants that each collated topic was a priority for prison health research in Canada for the next 10 years, and defined priorities based on the level of agreement.

RESULTS

In the first round, participants suggested 71 topics. In the second round, consensus was achieved that a large number of suggested topics were research priorities. Top priorities were diversion and alternatives to incarceration, social and community re-integration, creating healthy environments in prisons, healthcare in custody, continuity of healthcare, substance use disorders and the health of Aboriginal persons in custody.

CONCLUSIONS

Generated in an inclusive and systematic process, these findings should inform future research efforts to improve the health and healthcare of people who experience detention and incarceration in Canada.

A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.

Drug use prior to incarceration and associated socio-behavioural factors among males in a provincial correctional facility in Ontario, Canada

OBJECTIVES

To describe the prevalence of drug use in males in a provincial detention centre during the year before incarceration and to examine the association between socio-demographic and behavioural factors and drug use.

METHODS

In 2009, 500 adult males completed a survey after admission to a provincial detention centre in Ontario. Past-year prevalence rates were calculated for the use of opioids, cocaine, crack and methamphetamine, and by route of administration. Bivariate logistic regression was used to examine associations between drug use and socio-demographic and behavioural factors.

RESULTS

More than 56% of participants reported use of opioids, cocaine, crack or methamphetamine in the previous year. Risk factors for blood-borne and sexually transmitted infections were commonly reported for the previous year: 12.2% had injected drugs, 78.0% had had unprotected sex, and 48.0% had had more than one sexual partner. In unadjusted analyses, participants who were older than 24 years were more likely to have used any drugs and to have injected drugs in the previous year.

CONCLUSIONS

This study provides the first Canadian data in the past decade on drug use by recently incarcerated adults. We found that drug use and behaviours that increase the risk of transmission of sexually transmitted and blood-borne infections remain very common in this population. Incarceration provides an opportunity to provide services and links to programs for people who use drugs, which could decrease drug-related harms to individuals and society.

Prevalence and predictors of urethral chlamydia and gonorrhea infection in male inmates in an Ontario correctional facility

OBJECTIVES

To determine the prevalence of urethral chlamydia and gonorrhea in males in a correctional facility in Ontario, Canada, and to explore risk factors for infection.

METHODS

Between June and December, 2009, 500 adult males who had been newly admitted at a correctional facility in southern Ontario completed a survey of risk factors and provided a urine sample for testing. Those who tested positive were treated and their names were provided to the local public health unit for follow-up including contact tracing. Prevalence and 95% confidence intervals were calculated for infection with chlamydia and gonorrhea, respectively, and a multivariable model was used to look at risk factors for infection.

RESULTS

The study population reported high levels of sexual risk behaviours and drug use. The overall chlamydia prevalence was 2.9% (95% CI 1.6-4.8) and the overall gonorrhea prevalence was 0.6% (95% CI 0.1-1.8). Rates were particularly high for chlamydia in younger males, at 16% (95% CI 4.5-36) in 18-19 year olds and 3.7% (95% CI 1.0-9.3) in 20-24 year olds, and for gonorrhea in males aged 20-24 at 1.9% (95% CI 0.2-6.6). A multivariable logistic regression model revealed that though not statistically significant, younger age was associated with infection.

CONCLUSION

The relatively high prevalence of chlamydia and gonorrhea found in this study suggests that primary and secondary prevention programs should be instituted for males in correctional facilities, in particular among younger inmates. Further research is required to ensure internal and external generalizability of these results, as well as to determine the cost-effectiveness of potential interventions.

Endoscopic follow-up of positive fecal occult blood testing in the Ontario FOBT Project

BACKGROUND

The Ontario FOBT Project is a pilot study of fecal occult blood testing (FOBT) for colorectal cancer screening conducted among age-eligible volunteers (50 to 75 years) in 12 of 37 public health regions in Ontario.

METHODS

Volunteers responded to invitations from primary care practitioners (PCPs) in six regions, and from public health programs in the remaining regions. FOBT collection kits were distributed from routine laboratory specimen collection sites, to which completed kits were returned. Results were sent to PCPs in all 12 regions, with copies sent to the study office at Cancer Care Ontario (Toronto, Ontario). Follow-up of positive results was at the discretion of the PCPs. The study files contained the unique Ontario Health Insurance Numbers, the date of the analyses, the number of satisfactory slides and the results for each slide. The Ontario Health Insurance Numbers were encrypted for each participant, and along with the study file, were linked to medical billing claims, hospital records and aggregate demographic data.

RESULTS

Among participants with positive results (men 3.5% and women 2.2%), the median time from date of FOBT analysis to date of colonoscopy was 121 days among men and 202 days among women. At the end of follow-up, after positive FOBT (six to 17 months), 73% of men and 56% of women had proceeded to colonoscopy.

CONCLUSION

Although colonoscopy appeared to be acceptable to the majority of participants with positive FOBT, accessibility problems was the likely explanation for lengthy intervals between the date of positive FOBT and its performance. Differences between the experiences of men and women require further investigation.

Simplicity within complexity: seasonality and predictability of hospital admissions in the province of Ontario 1988-2001, a population-based analysis

Background

Seasonality is a common feature of communicable diseases. Less well understood is whether seasonal patterns occur for non-communicable diseases. The overall effect of seasonal fluctuations on hospital admissions has not been systematically evaluated.

Methods

This study employed time series methods on a population based retrospective cohort of for the fifty two most common causes of hospital admissions in the province of Ontario from 1988–2001. Seasonal patterns were assessed by spectral analysis and autoregressive methods. Predictive models were fit with regression techniques.

Results

The results show that 33 of the 52 most common admission diagnoses are moderately or strongly seasonal in occurrence; 96.5% of the predicted values were within the 95% confidence interval, with 37 series having all values within the 95% confidence interval.

Conclusion

The study shows that hospital admissions have systematic patterns that can be understood and predicted with reasonable accuracy. These findings have implications for understanding disease etiology and health care policy and planning.

Outbreak of serogroup C meningococcal disease caused by a variant of Neisseria meningitidis serotype 2a ET-15 in a community of men who have sex with men

We describe an outbreak, in a community of men who have sex with men, of serogroup C meningococcal disease caused by a genetic variant of the serotype 2a ET-15 Neisseria meningitidis characterized by a point mutation in the gene coding for the serotype 2a antigen. A microbiological characterization of the outbreak strain is presented in this report.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

[Effectiveness of psychoanalytically founded brief and dynamic psychotherapy]

OBJECTIVES

This study has been designed to investigate the effectivity of psychodynamic therapies.

METHODS

In a naturalistic prospective longitudinal study, 117 patients are compared with 116 untreated probands.

RESULTS

The improvement of the general psychosocial impairment of patients of clinical relevance and significance. The effective magnitude of change is high. Untreated patients show on the average no remission of impaired well-being and symptoms six months later.

CONCLUSION

Analytically orientated short-term psychotherapy and dynamic psychotherapy are effective in the treatment of many dysthymic and anxiety disorders as well as in the treatment of a number of personality disorders.

Agouti structure and function: characterization of a potent alpha-melanocyte stimulating hormone receptor antagonist

The murine agouti gene encodes for a novel 131 amino acid protein. The sequence includes a 22 residue putative secretion signal, an internal basic region, and a C-terminal domain containing 10 cysteines. Agouti has been found to antagonize the binding of certain pro-opiomelanocortin peptides, such as alpha-melanocyte stimulating hormone (alpha-MSH), to the murine melanocortin-1 receptor (MC1-R). We report the purification of a secreted murine agouti to homogeneity by a two-step procedure from baculovirus-infected Trichoplusia ni (T. ni). The protein is glycosylated and exhibits competitive, high-affinity antagonism (Ki = 0.8 nM) versus alpha-MSH in cell-based assays employing B16F10 cells. Association state analysis by analytical ultracentrifugation reveals that agouti exists in a monomer--dimer plus aggregate equilibrium at low micromolar concentrations. Data from secondary structure studies indicate that the protein is highly stable to thermal denaturation. Enzymatic digestion to probe disulfide bond arrangement yielded a discrete C-terminal (Val 83-Cys 131) domain. The isolated highly cysteine-rich C-terminal domain retains alpha-MSH antagonism equipotent with mature agouti. This bioactive domain contains all 10 cysteines which exhibit sequence homology when aligned with several conotoxins.

Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors

Endoscopic ultrasonography was used to examine 38 patients with a pancreatic neoplasm (mean size, 2.8 cm; range, 1 to 5 cm). Three EUS signs appear to be reliable criteria for the identification of tumor invasion of major veins forming the portal confluence: (1) peri-pancreatic venous collaterals in the area of a mass that obliterates the normal anatomic location of a major portal confluence vessel; (2) tumor within the vessel lumen; and (3) abnormal vessel contour with loss of the vessel-parenchymal sonographic interface. At least one of these signs was present in each of the 21 patients with vascular invasion; none of them was present in the 17 patients without vascular invasion. Findings were confirmed by laparotomy plus biopsy (33 patients), autopsy (1 patient), or angiography plus biopsy (4 patients). Arterial involvement was identified by alteration of vessel course and caliber. All 7 patients with arterial involvement also had venous involvement. These signs provide reliable criteria for endoscopic ultrasonographic definition of unresectable tumors in patients with a pancreatic neoplasm that appears to be resectable on standard radiologic tests.