The End of Evolution

Charles Darwin's theory of evolution was founded on the core belief that natural history is one of slow, incremental change, a concept he called "speciation." A hundred years later Eldredge and Gould challenged Darwin's theory, arguing that the data of paleontology reveals something quite different: long periods of stasis followed by bursts of change, a concept they called "punctuated equilibria." This article will follow that progression and then describe the three punctuated equilibria that I believe led to Homo sapiens. I argue that two of the three transitions are revealed in the hard data of the fossil record. The third is in the soft tissue of the brain. This third punctuated equilibrium placed Homo sapiens outside of evolution. Its arrival, 50,000 years ago, marked the beginning of the end of evolution.

Safety: From the Paris Morgue to Oxytocin

On Tuesday April 21, 1896, Freud gave a lecture to the Viennese medical community arguing that "hysteria," as it was then known, was caused by memories of actual physical and sexual abuse suffered in childhood. Freud rightly felt that he had made a major discovery about the science of hysteria, of psychotherapy, and of the mind. However, his idea was ridiculed. Freud's reaction to his detractors was swift: "They can go to hell." Freud withdrew "into a cocoon." When he emerged a year later, he brought with him a new science-the "science" of psychoanalysis, which for all its creativity and imagination, was devoid of science. One of the core concepts that would be sacrificed was safety itself. The "reality" of safety (and thus the reality of danger) was replaced by the "phantasy" of safety (and thus the phantasy of danger). This article reexamines some of the science that psychoanalysis took out. In particular the article looks at early attachment, safety, oxytocin, and the role of the autonomic nervous system. The reintroduction of science to psychotherapy is critical if psychotherapy is to be a science of the mind.

Calcinosis cutis arising in morphea: a case series

Calcinosis cutis, although common in systemic sclerosis, has been rarely reported in patients with morphea. We describe four patients with calcinosis cutis arising within morphea plaques, discuss their treatments and outcomes, and review previously published cases. Current management recommendations for concomitant morphea and dystrophic calcinosis cutis are based on limited data and expert opinion, which has primarily focused on reduction of active inflammation and reduction of symptoms related to calcinosis or ulceration. In most cases, no improvement of calcinosis was noted. The use of intralesional corticosteroids to active lesions in conjunction with systemic treatment, including methotrexate when indicated, appear promising treatments to halt progression of the disease. Surgical excision seems to be the most definitive treatment for calcinosis affecting morphea plaques, but the current literature lacks details regarding disease recurrence following operative management.

VIDAS Enzyme-Linked Fluorescent Immunoassay for Detection of Salmonella in Foods: Collaborative Study

The VIDAS SLM method for detection of Salmonella was compared with the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Twenty laboratories participated in the evaluation. Each laboratory tested one or more of 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. No significant differences (P< 0.05) were observed between the 2 methods. The 2 methods were in agreement for 99% of 1544 samples analyzed. Of the 20 samples out of agreement, 8 were VIDAS SLM positive and BAM/AOAC negative, and 12 were VIDAS SLM negative and BAM/AOAC positive. The VIDAS SLM method for detection of Salmonella in foods has been adopted first action by AOAC INTERNATIONAL.

Evolution, Shame, and Psychotherapy

Medea, the title character in Euripides' play, murdered her two sons in response to her husband Jason's abandonment. If her behavior can be understood, it is best understood in the context of shame. In an evolutionary context, shame is the affective response to the loss of one's place in the group. This response is related to the neurobiology of pain-not the acute pain experienced through the post-central gyrus, but the chronic, lingering pain that is experienced through the insular and cingulate cortices where homeostasis is regulated "from above." Shame is thus a fall in self-esteem, but shame is also a crisis of homeostasis, a crisis that can lead to drastic and, as in the case of Medea, violent attempts to "repair" the imbalance. Shame is a primitive, evolutionarily preserved response to the loss of one's place in the group.

NAP SACC UK: protocol for a feasibility cluster randomised controlled trial in nurseries and at home to increase physical activity and healthy eating in children aged 2-4 years

INTRODUCTION

Systematic reviews have identified the lack of intervention studies with young children to prevent obesity. This feasibility study examines the feasibility and acceptability of adapting the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention in the UK to inform a full-scale trial.

METHODS AND ANALYSIS

A feasibility cluster randomised controlled trial in 12 nurseries in England, with 6 randomly assigned to the adapted NAP SACC UK intervention: nursery staff will receive training and support from an NAP SACC UK Partner to review the nursery environment (nutrition, physical activity, sedentary behaviours and oral health) and set goals for making changes. Parents will be invited to participate in a digital media-based home component to set goals for making changes in the home. As this is a feasibility study, the sample size was not based on a power calculation but will indicate the likely response rates and intracluster correlations. Measures will be assessed at baseline and 8-10 months later. We will estimate the recruitment rate of nurseries and children and adherence to the intervention and data. Nursery measurements will include the Environmental Policy Assessment and Observation score and the nursery staff's review of the nursery environment. Child measurements will include height and weight to calculate z-score body mass index (zBMI), accelerometer-determined minutes of moderate-to-vigorous physical activity per day and sedentary time, and diet using the Child and Diet Evaluation Tool. Questionnaires with nursery staff and parents will measure mediators. A process evaluation will assess fidelity of intervention delivery and views of participants.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by Wales 3 NHS Research Ethics Committee. Findings will be made available through publication in peer-reviewed journals, at conferences and to participants via the University of Bristol website. Data will be available from the University of Bristol Research Data Repository.

TRIAL REGISTRATION NUMBER

ISRCTN16287377.

Aspects of psychodynamic neuropsychiatry III: magic spells, the placebo effect, and neurobiology

Through a case study, the importance of supporting the positive transference is stressed-from both a psychological and neurobiological perspective. The article argues that the neurobiology of expectation underlies transference. This neurobiology has been investigated particularly over the past several decades in work concerning the placebo effect. By understanding the neurobiology of expectation, one gains a better understanding of the neurobiology of the transference. This enables clinical predictions-and decisions-that are informed not just by the teachings of psychology but also by the science of biology.

Aspects of psychodynamic neuropsychiatry II: psychical locality and biology: toward the neurobiology of psychotherapy

Throughout his career, Freud believed that psychiatry in general and psychoanalysis in particular would one day be rooted in anatomical/biological ground. He felt confidant that such ground would replace the psychological understanding on which he had been forced to base most of his clinical theory and practice. He felt confidant that one day psychotherapy would be more "scientific." This article seeks to demonstrate that this day is arriving. A clinical case is presented where assessment and formulation are largely based on neurobiology, where treatment was conducted less in accord with psychodynamic theory than neurodynamic data of anatomy and biology.

Aspects of psychodynamic neuropsychiatry IV: love, ripe fruit, and other addictions

Passionate love is a powerful emotional/biological force. So too is heart-break a powerful emotional/biological force. This article studies the neurobiological underpinnings of the two. The argument is that passionate love is best understood not as an affective dysregulation but rather as an addiction. And similarly that heart-break is best understood, and treated, not as an affective dysregulation but as an addiction. Clinical examples are given.

Physically active families - de-bunking the myth? A qualitative study of family participation in physical activity

BACKGROUND

The benefits of physical activity for reducing obesity and related chronic diseases are well known. The need for more family-based interventions to increase physical activity is frequently cited in the literature; however, little is known about if and how families are physically active together, and what factors might influence family-based participation in regular physical activity. This study examined the types of activities (physical and sedentary) engaged in as a family and explored parents' perceptions of the importance, frequency, nature and barriers to family physical activity.

METHODS

Semi-structured telephone interviews were conducted with 30 parents (26 female, four male) of 10- to 11-year-old schoolchildren who attended either low, middle or high socio-economic status schools in Bristol, UK. Interviews were transcribed verbatim, anonymized and analysed using conventional content analysis.

RESULTS

The majority of parents rated family engagement in physical activity as important, and identified benefits such as increased parent-child communication, spending time together, enjoyment, enhanced mental health, weight control and physical fitness. Despite these benefits most parents reported their families did little or no physical activity together as a family unit during the week, and any activities performed together were usually sedentary in nature. They reported increased family physical activity on the weekends but rarely including the full family unit simultaneously. Parents in two-parent households commonly paired off with one or more children because of complexities of schedules. Commonly reported barriers were busy lifestyles, diverse ages and interests of children and adults, bad weather, and lack of access to facilities, transportation and money to support activities.

CONCLUSIONS

Family-based interventions might be more effective if they are designed to accommodate the complex demands and needs of two-parent and single-parent families and provide affordable, diverse activities appealing to a wide range of interests.

The slippery slope: touch in dynamic psychiatry

This article is a telescoped narrative of a seven year psychodynamic therapy with a chronically depressed, chronically suicidal, often paranoid woman who presented with a classic Borderline Personality Disorder. An unexpected and powerful moment of physical contact in an otherwise austere therapeutic relationship marked a turning point in a treatment that was blocked. After the patient and clinician integrated this experience, there was a subtle but significant change in the transference reflecting a change in her core paranoid structure.

Freud, Darwin, and the holding environment

Freud's hypothesis of the neonate, derived from the data of adult psychoneurotic patients, was of a supremely narcissistic being who lived in a dreamlike state of hallucinatory satisfaction. A corollary hypothesis was that the neonate's drive to attach was learned and emerged only after the failure of wish fulfillment. These hypotheses provided the ground for Freud's theories of regression, dream, primary process, and pleasure principle. Darwin's data of the neonate, collected from his observations of a variety of mammals, led him to the conclusion that attachment in mammals is innate. Until 1969 and the work of John Bowlby, psychoanalytic thinking faithfully followed Freud. If psychoanalysis is to survive, then it must attach itself to data and discard any theories that are based on unproveable hypotheses, even if those hypotheses are Freud's.

Acute hemodynamic effects of right ventricular pacing site and pacing mode in patients with congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy

The hemodynamic effects of pacing in patients with congestive heart failure (CHF) remain controversial. Early studies reported that pacing from the right ventricular (RV) apex improved acute hemodynamic parameters in patients with left ventricular systolic dysfunction, but these findings were not confirmed in subsequent controlled studies. More recently, it has been proposed that pacing from the RV side of the ventricular septum improves hemodynamic function compared with intrinsic conduction or apical pacing. Either dual-chamber or ventricular pacing have been evaluated, again with inconsistent findings. To assess the effects of pacing site and mode on acute hemodynamic function, we evaluated 21 subjects with CHF and intrinsic conduction disease. Hemodynamics were compared in AAI, VVI, and DDD modes with pacing from the RV apex or high septum. The pacing rate was constant in each patient and the order of testing was randomized. In the absence of ventricular pacing (AAI mode), the mean systemic arterial pressure was 85 +/- 11 mm Hg, the right atrial pressure was 11 +/- 4 mm Hg, the pulmonary capillary wedge pressure was 18 +/- 8 mm Hg and the cardiac index was 2.4 +/- 0.7 L/min/m(2). Compared with AAI pacing, there were no improvements in any hemodynamic parameter with DDD pacing from either RV site. Hemodynamic function worsened with VVI pacing from both RV sites. Subgroup analyses of patients with dilated cardiomyopathy, with prolonged PR interval, or with significant mitral regurgitation also failed to demonstrate an improvement with pacing. We conclude that pacing mode but not RV pacing site affects acute hemodynamic function. Pacing in the DDD mode prevents the deleterious effects of VVI pacing in this patient population.

Inappropriate shocks from implanted cardioverter defibrillators caused by sensing of diaphragmatic myopotentials

Inappropriate shocks remain one of the major problems associated with the use of implantable cardioverter defibrillators (ICD). We describe 3 patients who had inappropriate shocks due to oversensing of diaphragmatic myopotentials. In all 3, oversensing could be demonstrated during deep inspiration or Valsalva maneuver. The problem was remedied in one by insertion of a separate rate sensing lead in the right ventricular outflow tract, in the second by decreasing the rate of antibradycardia pacing of the ICD, and in the third by decreasing the sensitivity of the ICD. We conclude that the possibility of sensed diaphragmatic myopotentials should be considered at the time of ICD implant so that appropriate preventive measures can be taken.

Congenital pseudarthrosis of the tibia. Long-term followup of 29 cases treated by microvascular bone transfer

The authors show that vascularized fibular transplantation is the safest technique to treat congenital pseudarthrosis of the tibia. Results of transplantation in 29 patients reveal that the rate and speed of healing were superior to those of any other published method, and the final outcome at maturity was generally acceptable. In addition, the technique allows secondary lengthening procedures to be done. Various factors, such as age at first fracture, age at operation, gender, and type of fixation, did not appear to influence the outcome significantly.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)

A twelve-year survey of cervicothoracic vascular injuries

This study of a large series of victims of trauma to the cervicothoracic great vessels confirms the lethal potential of these injuries: more than half of victims of such injuries died. The optimal management of patients potentially harboring such vascular damage appears to include skilled prehospital resuscitation and rapid transport to a trauma center, a high index of diagnostic suspicion, a low threshold for the performance of contrast arteriography, aggressive surveillance for associated neurologic and aerodigestive tract injuries, and timely technical repair, including liberal indications for sternotomy or thoracotomy to assure vascular control.

Bone disease in prolonged parenteral nutrition: osteopenia without mineralization defect

A metabolic bone disease characterized by a mineralization defect, low plasma 1,25(OH)2D, and hypercalciuria has been described in patients receiving prolonged total parenteral nutrition (TPN). Because the practice of TPN differs from center to center, we investigated 13 home TPN patients to determine whether they had similar or different bone abnormalities. They had received TPN for a mean period of 51 +/- 38 mo. Bone pain occurred in six patients and two had multiple vertebral and rib fractures (with trauma in one patient). Bone pain was mild to moderate and not incapacitating. Bone histomorphometry showed reduced bone volume, reduced osteoid with normal resorption and calcification rates. These abnormalities were associated with hypercalciuria, but the plasma levels of 1,25(OH)2D were normal. Abnormalities in bone metabolism in this group of patients suggest a fundamental decrease in bone matrix-formation rather than a mineralization defect as the underlying mechanism.

Agitation, disorientation, and hallucinations in patients on cimetidine: a report of three cases and literature review

Cimetidine, the first of a new class of pharmacologic agents that dramatically inhibit basal gastric acid secretion, is achieving widespread use for the treatment of such acid peptic disorders as duodenal ulcers, gastritis, and reflux esophagitis. Three patients are presented who experienced agitation, disorientation, and hallucinations while being treated with cimetidine. A review of the literature revealed that central nervous system side effects of cimetidine can occur within 24 hours of treatment with the drug; are often unrecognized or misdiagnosed by clinicians, and are reversed within 12 to 48 hours after the discontinuation of the medication.