Methamphetamine, amphetamine, and aggression in humans: A systematic review of drug administration studies

The relationship between amphetamine use and aggressive or violent behaviour is unclear. This review examined laboratory data collected in humans, who were administered an acute dose of amphetamine or methamphetamine, in order to investigate the link between amphetamines and aggression. It is registered with PROSPERO (CRD42019127711). Included in the analysis are data from twenty-eight studies. Behavioural and/or subjective measures of aggression were assessed in one thousand and sixty-nine research participants, with limited amphetamine-use histories, following a single amphetamine dose (0-35mg). The available published evidence indicates that neither amphetamine nor methamphetamine acutely increased aggression as assessed by traditional laboratory measures. Future research should assess supratherapeutic amphetamine doses as well as include a broader range of multiple aggression measures, facilitating simultaneous assessment of the various components that comprise this complex, multifaceted construct.

Tricuspid valve complications during leadless pacemaker implantation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Minneapolis Heart Institute Foundation

Background

The implantation of a leadless right ventricular pacemaker (LPM) may be complicated by tricuspid valve injury or interference with tricuspid valve function.

Purpose

Characterize the nature, causes, and outcomes of tricuspid valve injury and functional interference due to LPM implantation.

Methods

The Food and Drug Administration’s Manufacturers and User Facility Device Experience (MAUDE) database was queried for tricuspid valve adverse events involving the Medtronic Micra LPM that were reported by the manufacturer.

Results

From 2016-October 2021, 19 patients suffered a tricuspid valve adverse event, including damage to the leaflets, papillary muscle, or chordae tendineae (n=14; 74%); interference with valve closure (n=3; 16%); and 2 LPMs were irretrievably wedged in the tricuspid valve apparatus. Damaged valves included: 1) torn leaflet or chordal tissue found in the delivery system (n=6) after complicated or failed LPM recapture that necessitated removal without the LPM retracted into the delivery system; all patients developed tricuspid regurgitation, and one patient died. 2) valve damage by the delivery system either directly (n=6) or during LPM recapture (n=1) or removal by a snare (n=1); all patients had new or worsening tricuspid regurgitation; one patient died, 2 had valve repair, and one valve was replaced. In three patients the LPM interfered with valve closure; one patient had valve replacement, one underwent LPM removal, and one was treated medically. Of the 2 LPMs wedged in the tricuspid valve apparatus, one required surgical removal and one was abandoned.

Conclusion

Tricuspid valve trauma during LPM implantation may cause significant regurgitation that results in poor outcomes and requires medical or surgical intervention. Mechanisms include direct valve injury by the delivery system, complications of difficult or unsuccessful LPM recapture, and LPM interference with valve function.

Professionals' perceptions of a multi-agency computerised data sharing system

We examined the perceptions of multi-agency child abuse investigation professionals following the implementation of an independent computerised data linkage system for case tracking purposes. Semi-structured interviews (N  = 30) were conducted with child protection workers and police officers, from both frontline and managerial roles, to explore their experiences in adapting to the new technology. Interview transcripts were coded and analysed using thematic analysis, focusing on the semantic meaning of the data. Four multifaceted themes were generated, of which three (understanding the rationale for change; system implementation and its limitations; and the role of technology within the organisational structure) showed strong divergence between frontline workers and management. While executives highlighted the benefits of the new system, frontline workers (overall) held a negative view about the system's usefulness and impact on workload. The implications of the findings are discussed.

Evaluation of the Aboriginal and Torres Strait Islander Mental Health First Aid Program

OBJECTIVE

This study reports findings from an uncontrolled evaluation of a course designed to educate participants in how to recognise and respond to mental health problems until professional help is received.

METHODS

Utilising a mixed methods design, participants in 21 different courses, delivered across two Australian states, were invited to complete pre-, post-, and follow-up surveys and provide qualitative feedback on their training experiences.

RESULTS

Participants reported feeling more confident in their capacity to respond appropriately to a person presenting with a mental health need and believed they would be more likely to provide assistance. Satisfaction was attributed to the skills and sensitivities of instructors who had lived experience of mental health concerns in Aboriginal and Torres Strait Islander communities.

CONCLUSION

This course holds promise in improving mental health literacy in relation to Aboriginal and Torres Strait Islander mental health. Implications for public health: Few courses are available that address issues relating to the social and emotional wellbeing of Aboriginal and Torres Strait Islander People. This study illustrates how community engagement with primary health and specialist mental health services might be strengthened.

P1077Late gadolinium enhancement with cardiac magnetic resonance imaging demonstrates left ventricular involvement is under-recognized in arrhythmogenic right ventricular cardiomyopathy

Funding Acknowledgements

The study is partially funded by Medtronic and the Minneapolis Heart Institute Foundation.

Background/Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by replacement of the myocardium with fibrous and fatty tissue that may lead to an increased risk of ventricular arrhythmias and heart failure.  Although left ventricular (LV) and biventricular forms have been identified post-mortem resulting in the increased use of the term arrhythmogenic cardiomyopathy, there is only inclusion of right ventricular wall motion abnormalities in the taskforce diagnostic criteria.

Purpose

The aim of our study was to examine the utility of cardiac magnetic resonance (CMR) imaging in characterizing LV or biventricular involvement with late gadolinium enhancement (LGE) in a large cohort of patients with suspected ARVC.

Methods

Retrospective, single-institution, chart review of 76 patients diagnosed with ARVC between January 2009 and July 2019. Data collection and analysis included baseline demographics and parameters specific to diagnosis (definite, borderline, or possible) and risk stratification of ARVC based on 2019 modified taskforce criteria, as well as detailed CMR evaluation.

Results

Of the 76 patients with ARVC, 66 (87%) had at least one CMR with gadolinium administered. In that subset of patients, 27 (41%) had LGE. Of those with LGE, LV involvement was identified in 23 (85%) patients. The pattern of LGE was not localized to one myocardial region but demonstrated variable LV enhancement patterns including anterior, inferior, lateral, septal, basal, mid, apical, and from the sub-epicardium into the mid-myocardium.

Conclusions

  Left ventricular involvement reflected by LGE was identified in a high percentage of patients with suspected ARVC, and there was significant variation in the pattern of distribution in terms of region and depth of myocardial involvement.  While post-mortem examination of patients with ARVC demonstrates a high prevalence of left ventricular involvement, this study shows that CMR can consistently detect late gadolinium enhancement, and ARVC should be considered in the differential diagnosis for biventricular cardiomyopathy.  The identification of variable locations of LGE within the LV suggests there is more than one phenotype, and this imaging modality may help to clarify the implications of left ventricular involvement in disease progression.

Clinicians' perspectives of forensic rehabilitation

Having sought 22 clinicians' views of how rehabilitation was practised in a forensic mental health service, this study explores whether or not these views are consistent with claims that forensic rehabilitation can be hampered by the lack of a coherent rehabilitation framework. Two major, mutually influencing themes emerged from the participants' narratives, the first of which delineates the culture and functioning of individuals and systems in a forensic service and the underlying philosophies and beliefs guiding professional behaviour. The second theme outlines the participants' views of the ways in which client needs are assessed and how clients are subsequently provided with the skills and opportunities required for their rehabilitation. The results indicate that while the participants perceived that there were positive aspects to the forensic mental health care that was provided; they also stated that systematicity in the formulation and provision of forensic mental health clients' needs was lacking. These findings reinforce previous claims that there needs to be a theoretically sound means of embedding and systematising effective rehabilitation practice in forensic services.

The Intensity and Timing of Sex Offender Treatment

Current evidence about the impact of specialized sex offender treatment on reoffending remains inconsistent, drawing attention to the need to focus more on those program characteristics that potentially moderate outcome. This review considers current professional perspectives and evidence on two defining aspects of treatment: its intensity and timing. It is concluded that insufficient evidence currently exists to articulate best practice in this area and there is a pressing need to collect empirical evidence about the effectiveness of different intensity treatments offered at different stages of sentence.

Assessing violence risk with Aboriginal and Torres Strait Islander offenders: considerations for forensic practice

Forensic professionals and courts have frequently expressed concern about the susceptibility of contemporary risk assessment tools to cultural bias. Furthermore, progress in the development of valid methods of assessment for offenders who identify from Aboriginal and Torres Strait Islander cultural backgrounds has been slow. This paper considers how cultural perspectives on risk are essential to the development of assessment methods that have greater validity and acceptance by both courts and the community. This will involve considering the social, cultural and political determinants of risk in each cultural group and the identification of those risk factors that are most relevant to forensic decision-making.

Drugs and Personality

In a previous paper one of us (4) has elaborated a theory relating drug action to personality. According to this theory, depressant drugs increase cortical inhibition (Pavlov) or reactive inhibition (Hull), thus producing an extraverting effect on personality, while stimulant drugs decrease inhibition and produce an introverting effect in behaviour. It was also suggested in this paper that a direct proof of the hypothesis might be obtained by making predictions regard ing the effects of stimulant and depressant drugs on a variety of experimental laboratory situations connected with the general theory of inhibition and excitation.

Young Offenders, Maltreatment, and Trauma: A Pilot Study

Although a large number of studies offer consistent and persuasive evidence that exposure to childhood maltreatment and subsequent juvenile offending behaviours are related, relatively few studies have investigated the mechanisms by which maltreatment might increase risk in young offender populations. The aim of this pilot study was to collate data on the key areas of need from 28 young male offenders in secure care in an Australian jurisdiction, with a specific focus on the inter-relationship between scores on self-report measures of maltreatment, trauma, and mental health. The findings provide preliminary evidence that these key constructs are linked to other proximal risk factors for juvenile offending, such as poor anger regulation and antisocial thinking patterns. They offer a rationale for considering the sequelae of maltreatment in the development of service delivery frameworks for young offenders.

Accountability in Juvenile Justice: A Framework to Assess Client Outcomes

This article describes the development of an assessment protocol for use with juvenile justice clients that can be used to assess needs in a manner that not only informs the development of case plans but also allows for the assessment of change over the course of a service contact. The youth justice assessment tool supports case needs identification and analysis as well as screening for mental health concerns, risk of harm to self or others, and risk of reoffending. Initial validation of the case needs component has been undertaken and although further validation is required, preliminary data reported in this article suggest that this type of approach to client assessment does hold some promise.

Refugee child oral health

The number of people forced to flee their homes and move around the world is increasing rapidly. Such refugee populations are not only more likely to have poor physical, mental and social health outcomes but also to experience difficulties accessing health services in their new country. In particular, children from refugee backgrounds are at increased risk of poor oral health which in time is associated with poor adult oral health and impacts on child health (e.g. growth and development) and well-being. To date, there is little evidence about the nature and extent of their oral health problems nor interventions to improve their oral health status. This article summarises the evidence surrounding the oral health status of children from refugee backgrounds. In addition, a systematic review of the international literature over the past 10 years is presented which identifies interventions to improve the oral health of these vulnerable paediatric populations. Based on this evidence, potential strategies available to dental service providers to optimise provision of responsive dental care are discussed.

Taking the Good Life to the Institution: Forensic Service Users' Perceptions of the Good Lives Model

Previous literature has highlighted a number of concerns about forensic care and rehabilitation by those who use the services. The Good Lives Model (GLM) is a strength-based, humanistic approach to offender rehabilitation that has been largely overlooked by forensic mental health practitioners. This study explored the impact of a brief GLM program on forensic service users' perceptions of rehabilitation, both within and beyond therapeutic programs, using a thematically linked, multiple-case study research design. Pre-post comparisons of participants' perceptions of rehabilitation suggested three different outcomes: definite change, subtle change, and no change. Possible factors associated with participants' divergent experiences included level of exposure to the GLM, readiness to change, and practitioners' adherence to the GLM and experience with the model. The importance of attending to the wider system for successful implementation of this innovative approach is highlighted.

Looking beyond the illness: forensic service users' perceptions of rehabilitation

The aim of this qualitative study was to explore perspectives on rehabilitation of those detained in a New Zealand forensic hospital setting. Twenty forensic service users participated in individual interviews, which were audio-taped, transcribed verbatim, and subjected to thematic analysis. The analysis identified seven themes that were broadly categorized into those that concerned the rehabilitation context (external) and those that more directly reflected the forensic service user's personal experience (internal). External themes highlighted a person-centered approach, the nature of relationships with staff, consistency of care, and awareness of the rehabilitation pathway. Internal themes related to forensic service users' self-evaluations, agency, and coping strategies. These findings are discussed within the broader context in which rehabilitation took place.

Assessing treatment readiness in violent offenders

Although violent offenders are widely considered to be difficult to engage in therapeutic change, few methods of assessing treatment readiness currently exist. In this article the validation of a brief self-report measure designed to assess treatment readiness in offenders who have been referred to violent offender treatment programs is described. The measure, which is an adaptation of a general measure of treatment readiness developed in a previous work, displayed acceptable levels of convergent and discriminant validity and was able to successfully predict treatment engagement in violent offender treatment. These results suggest that the measure has utility in the assessment of treatment readiness in violent offenders.

Symptoms of trauma, perceptions of discrimination, and anger: a comparison between Australian indigenous and nonindigenous prisoners

Although the need for the development and provision of culturally appropriate rehabilitation programs for offenders is widely acknowledged, there is a lack of empirical data that can be used as a basis for the development of new programs. This article reports the findings of a comparison of indigenous and nonindigenous male prisoners on a range of measures relevant to the experience of anger by indigenous prisoners in Australia. The results suggest that indigenous participants are more likely to experience symptoms of early trauma, have greater difficulties identifying and describing feelings, and perceive higher levels of discrimination than nonindigenous prisoners. The implications of this work for the development of culturally appropriate and effective anger management programs for indigenous male prisoners are discussed.

A longitudinal study of the learning and retention of task-specific training

This longitudinal study evaluated the learning and retention of task-specific training during the subjects' classroom performance of a one-person pivot transfer. Twelve subjects were videotaped completing the transfer (pretest). The subjects then participated in a two-hour training session. One week later (posttest 1), and one year later (posttest 2) the subjects were videotaped again. A checklist was used to analyze the videotapes. A one-way ANOVA with repeated measures revealed that there was a statistically significant difference between the tests (F = 243.73, p-value < 0.0001). A post hoc analysis (Bonferroni procedure) indicated that the posttest 1 scores (mean = 13, SD = 0.40) were significantly higher than the pretest scores (mean = 2.96, SD = 0.39) indicating an improved score on the checklist. There was no significant difference between the scores of posttest 1 and posttest 2 (mean = 12.79, SD = 0.60) indicating that subjects continued to perform the task with proper body mechanics one year post training.

Alcohol use and negative affect in the offence cycle

INTRODUCTION

It is commonly acknowledged that, for many offenders, alcohol use is strongly associated with criminal behaviour. The belief held by many professionals that the two phenomena are associated, probably in a causal way, has led to the inclusion of alcohol use as a 'criminogenic need' in many settings where rehabilitation programmes are used to reduce recidivism. However, the mechanisms and pathways involved in the alcohol crime link remain poorly understood.

ARGUMENT AND CONCLUSION

This paper reviews the literature relating to alcohol offending links and draws some inferences about the role of alcohol use as a criminogenic need in offender rehabilitation. It is proposed that the bi-directional relationship between alcohol use and negative affective states is important in understanding the offence cycle, and that deficits in self-regulation not only characterize both alcohol misuse and negative affect but are also implicated in the offending behaviour itself.

The effects of a multi-modal intervention trial of light, exercise, and vitamins on women's mood

The purpose of this study was to test the efficacy of a tri-modal intervention (LEVITY) to improve women's mood. This eight-week randomized experiment with a placebo-control group targeted women with symptoms of mild to moderate depression. Women in the intervention group were instructed to take a brisk 20-minute outdoor walk at target heart rate of 60% of maximum heart rate, to increase light exposure throughout the day and to take a specific vitamin regimen. Women in the control group took a daily placebo vitamin. The sample consisted of 112 women ages 19-78 who reported mild to moderate depressive symptoms. They were in otherwise good health and were not currently taking any mood-altering medication. Pre- and post-intervention assessment utilized live measures of mood: Center for Epidemiology Studies Depression Scale, Profile of Mood States, Depression-Happiness Scale, Rosenberg Self-Esteem Scale, and the General Well-Being Schedule. Analysis of covariance indicated that the intervention was effective in improving women's overall mood, self-esteem, and general sense of well-being and in decreasing symptoms on two measures of depression. Of particular note, the data from all five outcome measures supported the efficacy of the intervention. In addition, a high level of adherence to the intervention protocol was observed with two-thirds of the women reporting 100% adherence. Study implications suggest that this type of intervention may provide an effective, clinically manageable therapy for mild-to-moderately depressed women who prefer a self-directed approach or who have difficulties with the cost or side-effects of medication or psychotherapy.

Local health districts and the public health workforce: a case study of Wyoming and Idaho

This study of personnel in local health departments (LHDs) focused on two predominantly rural states: Idaho and Wyoming. Although in the same region of the country, the structure of local public health is different in each state. Idaho's regionalized LHDs are relatively autonomous, whereas Wyoming's are county based, with many public health functions retained at the state level. The majority of professionals are nurses followed by environmental health workers and sanitarians, similar to data reported nationally. With increased emphasis on core public health functions of policy, assurance, and assessment, rural LHDs will be challenged to redirect the functions of their workforce.

Interleukin (IL)-4 deficiency does not influence fatty streak formation in C57BL/6 mice

Abundant data is present to implicate oxidatively modified low-density lipoprotein (oxLDL) in enhanced atherogenesis. Among the factors involved in LDL oxidation, an important role has been attributed to human 15-lipoxygenase (LO) and its murine analog 12-LO. The expression of these peroxidizing enzymes is under the control of cytokines, the principal of which is IL-4. In the present study we tested the hypothesis that knocking out the IL-4 gene from C57BL/6 mice would result in suppression of fatty streaks. For this purpose, we have fed 45 female IL-4 transgenic knockout (IL-4T KO) and 45 wild-type (WT) mice an atherogenic diet for 15 weeks. Consecutive determinations of the lipid profile from both study groups were performed at monthly intervals, and fatty streak formation was assessed at the aortic sinus level, upon sacrifice. The two study groups did not differ significantly with respect to the lipid profile or the uptake and degradation of iodinated oxLDL by their peritoneal macrophages. We found that the endogenous deficiency of IL-4 did not confer protection from early atherosclerosis in the IL-4T KO as compared to their WT littermates (determined at the aortic sinus). Immunohistochemical studies, Western blots and 12/15-LO activity assays revealed the presence and activity of 12/15-LO in macrophages of WT mice as well as in IL-4T KO mice. Both did not differ significantly between the study groups. The data from this study imply that deficiency in IL-4 does not affect early atherosclerosis in C57BL/6 mice fed a high-cholesterol diet.

Altered sleeping arrangements in pediatric patients with epilepsy

Parental fears concerning seizure occurrence may be associated with behavioral changes within the home environment. One possible change involves sleeping arrangements. Questionnaires concerning demographics, medical history, and sleeping arrangements were completed by parents of 179 children with epilepsy and by parents of 155 children with diabetes for comparison purposes. Based on parental response, 40 (22%) children with epilepsy changed to less independent sleeping arrangements. Logistic regression suggested that parental concern over seizure occurrence was highly associated with this change (p=<0.001). In contrast, 13 (8%) of the children with diabetes changed to a less independent sleep pattern. Results suggest changes in sleeping arrangements may alert the pediatrician to possible parental anxiety that may need to be addressed.

Pregnancy intention: how PRAMS data can inform programs and policy. Pregnancy Risk Assessment Monitoring System

BACKGROUND

In most states, the Pregnancy Risk Assessment Monitoring System (PRAMS) is the only source for state-specific, population-based data on the prevalence of unintended pregnancy among women having a live birth. These data can be used in a variety of ways to inform state policies and programs aimed at the prevention of unintended pregnancy.

OBJECTIVES

This paper highlights the programmatic and policy development activities undertaken by three states in relation to unintended pregnancy as well as the role that PRAMS data played in those efforts.

RESULTS

Georgia, Oklahoma, and Washington have used PRAMS data to gain support for program initiatives directed at unintended pregnancy, to promote policies aimed at either monitoring or reducing unintended pregnancy, and to acquire additional funds for related programs, such as family planning.

The effects of N-6 polyunsaturated fatty acid supplementation on the lipid composition and atherogenesis in mouse models of atherosclerosis

Despite numerous studies, the precise role of dietary n-6 polyunsaturated fatty acids in the pathogenesis of atherosclerosis remains controversial. It has been shown that feeding an n-6-enriched diet resulted in decreased atherosclerosis in African green monkeys and was associated with a reduction in LDL levels. However, other authors reported that n-6 supplementation increased the oxidative stress and the susceptibility of LDL to undergo in vitro oxidation, thus potentially enhancing atherosclerosis. The present study was designed to investigate the effect of dietary supplementation of n-6 polyunsaturated fats (safflower oil), as compared with a saturated fat-rich diet (Paigen), on the blood lipid profile and atherosclerosis in two mouse models. In the first experiment, female C57BL/6 mice (n=23-30 per group) were fed a cholate containing Paigen diet, a safflower oil-rich diet (with cholate), or normal chow for 15 weeks. No significant differences between the high fat diet groups were evident with respect to total cholesterol, LDL, HDL or triglyceride levels. The extent of aortic sinus fatty streaks did not differ significantly between the two groups. In the second experiment, LDL-receptor-deficient (LDL-RD) mice (n=20-30 per group) were randomized into similar dietary regimens. Mice consuming a safflower oil-enriched diet developed significantly less atherosclerosis, in comparison with Paigen diet-fed mice. A reduction in LDL levels, although not of a similar magnitude as the reduction in atherosclerosis, was evident in the safflower oil-fed mice when compared to the Paigen diet-fed littermates. In both mouse models of atherosclerosis, LDL isolated from the plasma of mice on the n-6 polyunsaturated diet was rendered slightly more susceptible to oxidation in vitro, as indicated by a shorter lag period for diene formation. Thus, the effects of n-6 fatty acids on the lipoprotein composition and other potential influences may have contributed to the anti-atherogenic effect in the LDL-RD mouse model.

Nutritional effects of long-term gastrostomy feedings in children with cystic fibrosis

OBJECTIVE

To analyze the long-term nutritional effects of supplemental gastrostomy feedings in undernourished patients with cystic fibrosis.

DESIGN

Longitudinal, retrospective assessment of anthropometric measures before and for up to 4 years after gastrostomy.

SUBJECTS/SETTING

All patients at a large cystic fibrosis care center who underwent gastrostomy between 1980 and 1993 when they were at least 1 year old and were followed up for a minimum of 1 year after gastrostomy.

STATISTICAL ANALYSES PERFORMED

The Mann-Whitney U test was used to compare anthropometric values measured during 4 postgastrostomy time intervals with values measured during the year preceding gastrostomy.

RESULTS

The 21 patients ranged in age from 1.1 to 20.8 years (median age = 7.4 years). They had mild to moderate malnutrition at the time of gastrostomy. Patients were followed up for a mean of 39 months after gastrostomy. Supplemental feedings were associated with significant improvements in weight and height percentiles for age, and in weight as a percentage of ideal weight. Improvement in weight occurred earlier than improvement in height. Among subjects followed up for at least 18 months after gastrostomy, median weight percentile for age increased from 2% for the year before gastrostomy to 12% for the period 6 to 18 months after gastrostomy (P < .001) and 19% for the period 30 to 48 months after gastrostomy (P = .002 compared with before gastrostomy). Other nutritional parameters followed similar, although less dramatic patterns. Gastrostomy feedings were well tolerated and associated with only minor complications.

CONCLUSIONS

Long-term gastrostomy feedings appear to be a safe and effective means of improving nutrition in malnourished patients with cystic fibrosis. Clinical dietitians should function as care managers for patients with cystic fibrosis who are receiving supplemental gastrostomy feedings.

Worldwide patterns of mitochondrial DNA differentiation in the harbor seal (Phoca vitulina)

The harbor seal (Phoca vitulina) has one of the broadest geographic distributions of any pinniped, stretching from the east Baltic, west across the Atlantic and Pacific Oceans to southern Japan. Although individuals may travel several hundred kilometers on annual feeding migrations, harbor seals are generally believed to be philopatric, returning to the same areas each year to breed. Consequently, seals from different areas are likely to be genetically differentiated, with levels of genetic divergence increasing with distance. Differentiation may also be caused by long-standing topographic barriers such as the polar sea ice. We analyzed samples of 227 harbor seals from 24 localities and defined 34 genotypes based on 435 bp of control region sequence. Phylogenetic analysis and analysis of molecular variance showed that populations in the Atlantic and Pacific Oceans and east and west coast populations of these oceans are significantly differentiated. Within these four regions, populations that are geographically farthest apart generally are the most differentiated and often do not share genotypes or differ in genotype frequency. The average corrected sequence divergence between populations in the Atlantic and Pacific Oceans is 3.28% +/- 0.38% and those among populations within each of these oceans are 0.75% +/- 0.69% and 1.19% +/- 0.65%, respectively. Our results suggest that harbor seals are regionally philopatric, on the scale of several hundred kilometers. However, genetic discontinuities may exist, even between neighboring populations such as those on the Scottish and east English coasts or the east and west Baltic. The mitochondrial data are consistent with an ancient isolation of populations in both oceans, due to the development of polar sea ice. In the Atlantic and Pacific, populations appear to have been colonized from west to east with the European populations showing the most recent common ancestry. We suggest the recent ancestry of European seal populations may reflect recolonization from Ice Age refugia after the last glaciation.

Evaluation of the circle of Willis with three-dimensional CT angiography in patients with suspected intracranial aneurysms

PURPOSE

To determine the usefulness of CT angiography in the setting of suspected acute subarachnoid hemorrhage or intracranial aneurysm.

METHODS

We prospectively studied 68 patients suspected of having subarachnoid hemorrhage or an intracranial aneurysm with noncontrast CT of the head followed immediately by contrast-enhanced helical CT of the circle of Willis with three-dimensional reconstruction. Twenty-seven patients with CT findings positive for subarachnoid hemorrhage or intracranial aneurysm were evaluated with digital subtraction angiography or MR angiography within 12 hours of CT angiography. Patients with negative CT/CT angiography findings were followed up with lumbar puncture.

RESULTS

CT angiography showed 23 of 24 aneurysms and 2 of 2 arteriovenous malformations (sensitivity, 96%; specificity, 100%). Aneurysm size ranged from 2 to 40 mm (mean, 7.9 mm). Interobserver variability was 10%. In the 23 cases of subarachnoid hemorrhage, cisternal blood did not limit the three-dimensional reconstruction. Two patients with aneurysms on CT angiography had normal noncontrast scans.

CONCLUSIONS

CT angiography of the circle of Willis is a useful technique for evaluation of suspected acute subarachnoid hemorrhage and intracranial aneurysm. It provides anatomic display of intracranial aneurysms, allowing for planning of conventional angiography and surgical approach. In selected cases, CT angiography may eliminate the need for preoperative conventional angiography.

Randomized trial of chemoendocrine therapy started before or after surgery for treatment of primary breast cancer

PURPOSE

To evaluate in a randomized clinical trial systemic chemoendocrine therapy used as primary (neo-adjuvant) treatment before surgery in women with primary operable breast cancer.

PATIENTS AND METHODS

Patients aged less than 70 years with clinically palpable, primary operable breast cancer diagnostically confirmed by fine-needle aspiration cytology (FNAC) and suitable for treatment with surgery, radiotherapy, cytotoxic chemotherapy, and tamoxifen were considered eligible. Patients randomized to neoadjuvant treatment received four cycles of chemo-therapy for 3 months before surgery followed by another four cycles after surgery, and were compared with patients randomized to adjuvant therapy who received eight cycles of chemotherapy over 6 months after surgery.

RESULTS

Of 212 patients who were randomized to receive either adjuvant (n = 107) or neoadjuvant (n = 105) chemoendocrine therapy, 200 are now assessable for response. The two groups are comparable for age, menopausal status, disease stage, and surgical requirements. The overall clinical response rate was 85%, with a complete histologic response rate of 10%. There was a significant reduction in the requirement for mastectomy in patients who received neoadjuvant treatment (13%) as compared with those who received adjuvant therapy (28%) (P < .005). Symptomatic and hematologic acute toxicity was low and similar for adjuvant and neoadjuvant therapy. The median follow-up period for patients in this trial is 28 months, during which time four patients have relapsed locally and 20, including one of the local relapses, have developed metastatic disease, 19 of whom have died. The follow-up period is too brief to evaluate relapse rate or survival duration.

CONCLUSION

This trial confirms previous reports of a high rate of response to neoadjuvant therapy, but is the first to include small primary cancers and to show, in the context of a randomized trial, a reduction in the requirement for mastectomy. Until disease-free and overall survival data are available from the larger National Surgical Adjuvant Breast and Bowel Project (NSABP)-18 trial, such neoadjuvant treatment cannot be recommended outside of a clinical trial.