'A kindergarten teacher must have 100 eyes and 100 ears!': Kindergarten teachers' experiences coping with child sexual abuse and problematic sexual behavior

BACKGROUND

Child sexual abuse (CSA) and problematic sexual behavior (PSB) are worldwide phenomena that occur across all ages. Kindergarten teachers' proactive involvement can be crucial to the prevention, disclosure and intervention of CSA and PSB. However, research on their experiences of contending with CSA and PSB remains limited.

OBJECTIVE

This study examines kindergarten teachers' experiences in Israel with the CSA and PSB of their students.

PARTICIPANTS AND SETTING

Semi-structured interviews were conducted with 31 teachers: 11 secular Jewish, seven religious Jewish, nine Druze Arab, and four Muslim Arab.

METHODS

A qualitative analysis was conducted using the interview transcripts as data.

RESULTS

The analysis revealed three themes illustrating teachers' professional transformations regarding their knowledge of these phenomena: 1) initial shock, uncertainty and sense of responsibility when exposed to CSA and PSB due to missing knowledge, 2) implementation of prevention and intervention strategies regarding CSA and PSB, and 3) embracing a social role to disseminate CSA and PSB knowledge. The findings indicated that the majority of the teachers went from overwhelming shock and fear due to a lack of knowledge in coping with CSA and PSB to a sense of responsibility as a community leader.

CONCLUSIONS

The fragmentation of the Israeli education system isolates kindergartens, and the lack of training and education for the teachers left them alone when contending with the CSA and PSB of their students. Nevertheless, the participants exhibited remarkable agency and resourcefulness, gaining the necessary knowledge and acting as knowledge agents within their communities.

Antipsychotics and Identity: The Adverse Effect No One is Talking About

People who take antipsychotics, and people who are prescribed antipsychotics without taking them, experience effects which are not frequently discussed: effects on their identity and sense of self. Qualitative research indicates the relationship between taking APs and identity is multilayered, and changeable. Taking APs can restore people to their earlier, pre-symptom sense of self. Being prescribed and taking APs can also, on the other hand, be experienced as damaging, erasing and dulling people's sense of who they are. This complexity deserves exploration in clinical practice, which we believe is currently not done routinely. More work is needed to understand whether, and how, the relationship between identity and APs is being addressed. We outline the importance of having discussions in a clinical space around identity, and a sense of agency, on the grounds that true recovery-oriented care, which enacts shared decision-making principles, demands it. Further, we argue that it will allow for better therapeutic alliance and trust to be forged between clinician and client, ultimately leading to better care.

International consensus statement on the design, delivery and evaluation of sport-based interventions aimed at promoting social, psychological and physical well-being in prison

OBJECTIVE

To develop an international consensus statement to advise on designing, delivering and evaluating sport-based interventions (SBIs) aimed at promoting social, psychological and physical well-being in prison.

DESIGN

Modified Delphi using two rounds of survey questionnaires and two consensus workshops.

PARTICIPANTS

A multidisciplinary panel of more than 40 experts from 15 international jurisdictions was formed, including representation from the following groups and stakeholders: professionals working in the justice system; officials from sport federations and organisations; academics with research experience of prisons, secure forensic mental health settings and SBIs; and policy-makers in criminal justice and sport.

RESULTS

A core research team and advisory board developed the initial rationale, statement and survey. This survey produced qualitative data which was analysed thematically. The findings were presented at an in-person workshop. Panellists discussed the findings, and, using a modified nominal group technique, reached a consensus on objectives to be included in a revised statement. The core research team and advisory board revised the statement and recirculated it with a second survey. Findings from the second survey were discussed at a second, virtual, workshop. The core research team and advisory board further revised the consensus statement and recirculated it asking panellists for further comments. This iterative process resulted in seven final statement items; all participants have confirmed that they agreed with the content, objectives and recommendations of the final statement.

CONCLUSIONS

The statement can be used to assist those that design, deliver and evaluate SBIs by providing guidance on: (1) minimum levels of competence for those designing and delivering SBIs; (2) the design and delivery of inclusive programmes prioritising disadvantaged groups; and (3) evaluation measures which are carefully calibrated both to capture proposed programme outcomes and to advance an understanding of the systems, processes and experiences of sport engagement in prison.

Methodological reflections on artistically illustrating ethnographic text from a study of sport pedagogy in youth detention: Ethics, affect, and description

While there is a burgeoning body of literature on visual methods in ethnography, including drawing and illustration as method for collecting and exploring data, little has been written about how artistic illustrations can be used as a representational method for finished ethnographic texts. Based on an illustrated ethnography–a PhD thesis on sport pedagogy in youth detention–this paper explores what artistic illustrations can do for representations of ethnographic texts. An important starting point of the paper is that artistic illustrations are purpose-full–they can be used strategically to highlight some details over others, thus making it possible for researchers to selectively accomplish several aims when it comes to representation. Particularly, we focus on ethical, affective, and descriptive purposes for using artistic illustrations when publishing research on sport in total institutions. We present selected illustrations from the thesis together with analytical and procedural commentary to shed light on some strategic thinking behind the production of the illustrations. Finally, we conclude with some reflections on the methodology and discuss some further considerations for illustrating ethnographic texts in terms of benefits, risks, and possibilities.

School principals coping with child sexual abuse in their schools

BACKGROUND

Schools serve a central role in prevention, disclosure and intervention in cases of child sexual abuse (CSA). As school principals often face CSA cases in their daily work, they may hold the key to making social change on this front. However, research on principals' experiences of contending with CSA remains limited.

OBJECTIVE

The current study is part of a larger qualitative research project examining various Israeli educators' coping with CSA among their students in diverse cultural contexts. In this study, we specifically focused on principals. The research questions were: (1) What are the unique ways in which school principals cope with cases of CSA during their course of daily work? (2) Do their cultural contexts and cultural affiliations shape their coping, and if so, how?

METHODS

In-depth interviews were conducted with 25 principals from multiple cultural groups (secular, religious and ultra-Orthodox Jews, and Arab-Muslims), which were analyzed using a thematic approach.

RESULTS

The findings indicated that principals demonstrate three types of coping strategies in response to encounters with CSA in the course of their work: they may act as "navigators" (exclusively responsible); "sharers" (rely on teamwork); or "balancers" (negotiating between cultural and legal demands). Furthermore, two contextual factors affected their construction of coping: ongoing professional experience in cases of CSA and personal experiences, including being a CSA survivor.

CONCLUSIONS

This study highlights the importance of principals in identifying and leading interventions for CSA cases. It also raises the need for training to combine reflective, experience-based practice alongside evidence-informed practice.

Headspace, a youth integrated care model: The relation between users satisfaction, clinical and demographic characteristics and service utilization

Introduction

Youth integrated care services were developed to overcome common barriers to mental health treatment. Satisfaction is key for services utilization and engagement.

Objectives

To study users satisfaction with youth integrated care service, “Headspace”, throughout the course of treatment and its correlation with clinical and demographic characteristics and service utilization.

Methods

A sample of 112 participants ranging between ages 12-25 who attended the Headspace clinic between March 2016 and June 2018 were assessed in the middle (after 7 sessions) and end of treatment (n=71).

Results

Participants expressed high levels of satisfaction across all service aspects at the middle and end of treatment. The highest rate of satisfaction was with the centre’s staff and the lowest with personal outcomes. A repeated measures ANOVA analysis revealed that only satisfaction with personal outcomes improved significantly over time Length of wait to begin treatment and parental engagement y were negatively correlated with youth satisfaction.

Conclusions

Satisfaction rates of Headspace among youth are high from the start and with their outcomes increase over time. Youth satisfaction with the staff’s attitude and approach and satisfaction with accessibility suggest the service achievement in addressing barriers of help seeking in youth.

Disclosure

No significant relationships.

Bipolar Stigma in Jewish Communities in the United States

Introduction

This study investigated differences in mood disorder public stigma endorsed by Jewish adults. Specifically, it examined the association between public stigma and the symptomatology and gender of individuals with mood disorders and characteristics of respondents. The symptomatology investigated included major depressive disorder and bipolar disorder presenting with mania or depression. The public stigma factors measured for mood disorders were recovery, relationship disruption, hygiene, anxiety, and treatment/professional efficacy.

Objectives

Do symptomatology and gender predict stigma for mood disorders? For Jewish adults, do gender, age, religious characteristics, mental health history, and perceived stigma for mental illness predict their stigma toward individuals with mood disorders?

Methods

A convenience sample of 243 Jewish adults were randomly administered vignettes using a factorial design. MANCOVA was used for analysis. The Mental Illness Stigma Scale (Day et al., 2007) and the Devaluation of Consumer scale (Struening et al., 2001) were used to measure public and perceived stigma respectively.

Results

showed that recovery, relationship disruption, and hygiene stigmas were associated with vignette subject symptomatology, an interaction was found between respondent gender and age for treatability/professional efficacy stigma, and perceived stigma was correlated with public stigma factors. Consistent with previous research, the highest levels of stigma were found for individuals with bipolar disorder presenting with mania (Wolkenstein & Meyer, 2008).

Conclusions

These findings increase our knowledge of mood disorder stigma existing in the Jewish community and supports research showing that bipolar disorder presenting with mania is the most stigmatized type of mood disorder symptomatology (Wolkenstein & Meyer, 2008).

Disclosure

No significant relationships.

Promoting better mental health care for patients with psychosis by focusing on differences in causal beliefs between patients and clinicians

Introduction

Nonadherence to antipsychotic medications and disengagement from psychiatric services are frequent among people with psychosis. Research indicates how the beliefs of people with psychosis about the etiology of their symptoms, or their causal beliefs, affect treatment choice and outcomes. Yet, there is less research on causal beliefs of clinicians or on the impact of patient–clinician disagreements on treatment and adherence.

Objectives

This review aimed to explore the scope of the literature focusing on clinicians’ causal beliefs and to map the degree of patient–clinician concordance in causal beliefs.

Methods

A systematic literature search of PubMed, Embase, Scopus, PsycInfo, and ASSIA and a grey literature search of PsyArXiv and MedNar yielded 11,821 eligible references.

Results

Forty-two articles indicated that whereas clinicians endorse mainly biogenetic beliefs (9/15 articles, 60%), patients endorse mainly psychosocial causal beliefs (16/31, 52%) and other non-biogenetic causal beliefs (8/31, 26%). Most studies did not compare causal beliefs of people with psychosis and their treating clinicians.

Conclusions

While clinicians and people with psychosis often hold complex causal models, a gap in causal beliefs between these groups appears to exist, which may affect the therapeutic relationship and pose barriers to treatment adherence. Future studies should address this gap by developing interventions that facilitate open communication about causal beliefs to promote treatment alliance and an agreed-on treatment plan.

Disclosure

No significant relationships.

Longitudinal assessment of nonavalent vaccine HPV types in a sample of sexually active African American women from ten U.S. Cities

BACKGROUND

Chronic infection with high-risk human papillomavirus is a necessary cause for cervical carcinogenesis. This study examined prevalence of nonavalent vaccine preventable HPV types over four months among sexually active women in the United States.

METHODS

This sub-study obtained meta-data for 80 of the 1,365 women (18-25 years), enrolled in the BRAVO study, a randomized, open-label trial of home screening and treatment of asymptomatic bacterial vaginosis at high-risk for sexually transmitted infections conducted between 2008 and 2013. Participants were randomized to treatment or standard-of-care, and followed every 2-months for 12 months. Stored vaginal swabs from the first three visits were tested for the nine vaccine preventable HPV types using quantitative PCR. Prevalence and associated 95% confidence intervals for the HPV types were assessed using R (version 3.6.1).

RESULTS

The average age of the participants was 21.5 (SD ± 2.11) years, with 60% having ever been pregnant and all were African-American. Majority (71%) reported ≥ two sex partners in the prior year with 89% having unprotected vaginal sex and 45% having a new sex partner in the prior year. About 30% had ≥ one of the nine nonavalent vaccine HPV types at all three time points over a period of four months, 15% at two of any three visits, 19% at one of the three visits and 36% were negative for all nine vaccine HPV types at all time points. The most frequently detected HPV vaccine types were 52, 58, 16, and 18. The prevalence of any vaccine HPV types, and high-risk HPV types was 63.8% and 58.8%, respectively.

CONCLUSIONS

Our findings suggest that HPV vaccination which is currently recommended for all unvaccinated persons through age 26 years, is likely to be more beneficial than previously thought as nonavalent HPV vaccine was not available during the time these data were collected.

The Sleep Side of Aging and Alzheimer's Disease

As we age, sleep patterns undergo significant modifications in micro and macrostructure, worsening cognition and quality of life. These are associated with remarkable brain changes, like deterioration in synaptic plasticity, gray and white matter, and significant modifications in hormone levels. Sleep alterations are also a core component of mild cognitive impairment (MCI) and Alzheimer's Disease (AD). AD night time is characterized by a gradual decrease in slow-wave activity and a substantial reduction of REM sleep. Sleep abnormalities can accelerate AD pathophysiology, promoting the accumulation of amyloid-β (Aβ) and phosphorylated tau. Thus, interventions that target sleep disturbances in elderly people and MCI patients have been suggested as a possible strategy to prevent or decelerate conversion to dementia. Although cognitive-behavioral therapy and pharmacological medications are still first-line treatments, despite being scarcely effective, new interventions have been proposed, such as sensory stimulation and Noninvasive Brain Stimulation (NiBS). The present review outlines the current state of the art of the relationship between sleep modifications in healthy aging and the neurobiological mechanisms underlying age-related changes. Furthermore, we provide a critical analysis showing how sleep abnormalities influence the prognosis of AD pathology by intensifying Aβ and tau protein accumulation. We discuss potential therapeutic strategies to target sleep disruptions and conclude that there is an urgent need for testing new therapeutic sleep interventions.

Sleep, Noninvasive Brain Stimulation, and the Aging Brain: Challenges and Opportunities

As we age, sleep patterns undergo severe modifications of their micro and macrostructure, with an overall lighter and more fragmented sleep structure. In general, interventions targeting sleep represent an excellent opportunity not only to maintain life quality in the healthy aging population, but also to enhance cognitive performance and, when pathology arises, to potentially prevent/slow down conversion from e.g. Mild Cognitive Impairment (MCI) to Alzheimer's Disease (AD). Sleep abnormalities are, in fact, one of the earliest recognizable biomarkers of dementia, being also partially responsible for a cascade of cortical events that worsen dementia pathophysiology, including impaired clearance systems leading to build-up of extracellular amyloid-β (Aβ) peptide and intracellular hyperphosphorylated tau proteins. In this context, Noninvasive Brain Stimulation (NiBS) techniques, such as transcranial electrical stimulation (tES) and transcranial magnetic stimulation (TMS), may help investigate the neural substrates of sleep, identify sleep-related pathology biomarkers, and ultimately help patients and healthy elderly individuals to restore sleep quality and cognitive performance. However, brain stimulation applications during sleep have so far not been fully investigated in healthy elderly cohorts, nor tested in AD patients or other related dementias. The manuscript discusses the role of sleep in normal and pathological aging, reviewing available evidence of NiBS applications during both wakefulness and sleep in healthy elderly individuals as well as in MCI/AD patients. Rationale and details for potential future brain stimulation studies targeting sleep alterations in the aging brain are discussed, including enhancement of cognitive performance, overall quality of life as well as protein clearance.

Effect of Diindolylmethane on Estrogen-related Hormones, Metabolites and Tamoxifen Metabolism: Results of a Randomized, Placebo-controlled Trial

Dietary supplement use is high among breast cancer survivors. One compound natural to cruciferous vegetables, diindolylmethane (DIM), is among the supplements commonly used. This bioactive compound has significant experimental evidence for bioactivity in breast chemoprevention. Sparse evidence in the form of well-designed human clinical trials exist to test its efficacy or safety. Methods: In this double-blind placebo-controlled study women taking tamoxifen for breast cancer primary or tertiary prevention were randomly assigned to receive 150 mg DIM (BioResponse(BR)-DIM) twice daily or a placebo for a minimum period of 12 months. Primary outcome was change in urinary estrogen metabolites 2-hydroxyestrone and 16α-hydroxyestrone (baseline to 6 weeks, 6 and 12 months). Secondary endpoints included breast density by mammogram and fat:water ratio MRI (baseline to 12 months) and serum estrogens (baseline to 6, 12 months). Safety data were also evaluated, including tamoxifen metabolites. Results: Adherence to study pills was >91% by pill count and urinary DIM metabolite assessment. In participants assigned DIM there was a significant and sustained shift in urinary estrogen metabolism favoring a higher 2-OH:16α-OH ratio; sex hormone binding globulin (SHBG) was also increased. No change in breast density was demonstrated. Safety analysis showed no appreciable differences in adverse events by treatment arm; however, tamoxifen metabolism for the parent compound as well as endoxifen and 4-OH endoxifen were appreciably reduced in women assigned to the DIM arm. Conclusions In this first large study of DIM in the setting of breast cancer chemoprevention, a favorable shift in estrogen metabolism and SHBG was demonstrated. However, the reduction in tamoxifen metabolites raises concern regarding the potential interaction between DIM and tamoxifen, an area in need of continued research. Impact Given the widespread and generally unsupported use of dietary supplementation by breast cancer survivors, these data will help to inform the use of DIM as a dietary supplement for breast cancer patients receiving tamoxifen.

Self and narrative in schizophrenia: time to author a new story

The prevailing, clinical view of schizophrenia, as reflected in the psychiatric literature, suggests both that people with schizophrenia have lost their sense of self and that they have a diminished capacity to create coherent narratives about their own lives. Drawing on our empirical research in the growing area of recovery, we describe not only the disruptions and discontinuities introduced by the illness and its social and personal consequences, but also the person's efforts to overcome these, to reconstruct a sense of self, to regain agency and to create a coherent life narrative. We suggest in closing that, rather than simply being a byproduct of recovery, these processes of re-authoring one's life story are actually integral components of the recovery process itself.

Cost effectiveness of defibrillation by targeted responders in public settings

BACKGROUND

Out-of-hospital cardiac arrest is frequent and has poor outcomes. Defibrillation by trained targeted nontraditional responders improves survival versus historical controls, but it is unclear whether such defibrillation is a good value for the money. Therefore, this study estimated the incremental cost effectiveness of defibrillation by targeted nontraditional responders in public settings by using decision analysis.

METHODS AND RESULTS

A Markov model evaluated the potential cost effectiveness of standard emergency medical services (EMS) versus targeted nontraditional responders. Standard EMS included first-responder defibrillation followed by advanced life support. Targeted nontraditional responders included standard EMS supplemented by defibrillation by trained lay responders. The analysis adopted a US societal perspective. Input data were derived from published or publicly available data. Future costs and effects were discounted at 3%. Monte Carlo simulation and sensitivity analyses assessed the robustness of results. Standard EMS had a median of 0.47 (interquartile range [IQR]=0.32 to 0.69) quality-adjusted life years and a median of 14 100 dollars (IQR=8600 dollars to 21 900 dollars) costs per arrest. Targeted nontraditional responders in casinos had an incremental cost of a median 56 700 dollars (IQR=44 100 dollars to 77 200 dollars) per additional quality-adjusted life year. The results were sensitive to changes in time to defibrillation, incidence of arrest, and number of devices required to implement rapid defibrillation.

CONCLUSIONS

Where cardiac arrest is frequent and response time intervals are short, rapid defibrillation by targeted nontraditional responders may be a good value for the money compared with standard EMS. The incidence of arrest should be considered when choosing locations to implement public access defibrillation.

Progressing from patienthood to personhood across the multidimensional outcomes in schizophrenia and related disorders

The conceptualization of outcome in schizophrenia has been modified since Krapelin's dementia praecox and is now thought to be more heterogeneous and multidimensional. Qualitative research reveals a deeper and more complete understanding of the complex processes involved. This study investigates and describes the subjective experience of the multidimensional outcome of schizophrenia. The findings are based on bimonthly comprehensive assessments conducted over a 1-year period with 43 persons who were hospitalized for schizophrenia and related disorders. Results reveal ongoing person-environment interactions, which constitute the nonlinear progression from "patienthood" to 'personhood" across the multidimensional outcome domains of work, treatment, and social relationship. To facilitate this difficult process, it is essential to simultaneously help consumers develop their strengths and increase society's awareness and commitment to meet their unique needs.

Differences in self-disclosure in psychotherapy between American and Israeli patients

This study investigated differences in extent and patterns of disclosure in psychotherapy between American (n = 164) and Israeli (n = 45) patients. Participants completed the Disclosure to Therapist Inventory-R, an 80-item measure that uses a rating scale to assess the extent to which psychotherapy patients have discussed each of 80 moderately to highly intimate topics with their most recent therapist. Analysis yielded no significant difference between groups in overall disclosure and high overlap in the topics most and least discussed. Both groups frequently discussed aspects of their personalities they disliked, feelings of desperation or depression, and feelings of rage or anger towards parents. Findings suggest universal concerns may outweigh the cultural context in which therapy occurs.

Comparing patients' and staff members' attitudes: does patients' competence to disagree mean they are not competent?

The ability to process and compare the benefits and risks of a proposed treatment is considered an important component of being competent to make treatment decisions. Whether psychiatric patients' expressed treatment choice reflects their personal preferences or a deficit in their decision-making process is unclear. The aim of the study was to assess the extent to which patients and staff agree or not on various treatment-related issues. A literature search was conducted to identify published articles comparing the perceptions and attitudes of staff and patients toward various treatment issues. Twenty-eight published articles over the last 40 years were located and their main findings summarized. Analysis of the findings revealed disagreement between patients and staff in 26 of the 28 articles. The consistency of the disagreement over time and across studies suggests that the disagreement might have more to do with the fundamental difference between being a patient and a staff member rather than a patient's cognitive deficits or psychopathology. It is crucial that both patients and staff work toward building bridges when discord appears consistent and pervasive.

Phase I/II study of the P-glycoprotein modulator PSC 833 in patients with acute myeloid leukemia

PURPOSE

To determine the maximum-tolerated dose, pharmacokinetic interaction, and activity of PSC 833 compared with daunorubicin (DNR) and cytarabine in patients with poor-risk acute myeloid leukemia.

PATIENTS AND METHODS

Patients received ara-C 3 g/m(2)/d on 5 consecutive days, followed by an IV loading dose of PSC 833 (1.5 mg/kg) and an 84-hour continuous infusion escalating from 6, 9, or 10 mg/kg/d. Daunorubicin was administered as a 72-hour continuous infusion at 34 or 45 mg/m2/d [corrected]. Responding patients received consolidation chemotherapy with DNR pharmacokinetics performed without PSC-833 on day 1, and with PSC-833 on day 4. Response was correlated with expression of P-glycoprotein and lung resistance protein (LRP), and in vitro sensitization of leukemia progenitors to DNR cytotoxicity by PSC 833.

RESULTS

All 43 patients are assessable for toxicity and response. Grade 3 or greater hyperbilirubinemia (70%) was the only dose-dependent toxicity. Four patients (9%) succumbed to treatment-related complications. Twenty-one patients (49%) achieved a complete remission or restored chronic phase, including 10 of 20 patients treated at the maximum-tolerated dose of 10 mg/kg/d of PSC-833 and 45 mg/m(2) of DNR. The 95% confidence interval for complete response was 33.9% to 63.7%. Administration of PSC 833 did not alter the mean area under the curve for DNR, although clearance decreased approximately two-fold (P =.04). Daunorubicinol clearance decreased 3.3-fold (P =.016). Remission rates were not effected by mdr-1 expression, but LRP overexpression was associated with chemotherapy resistance.

CONCLUSION

Combined treatment with infused PSC 833 and DNR is well tolerated and has activity in patients with poor risk acute myeloid leukemia. Administration of PSC 833 delays elimination of daunorubicinol, but yields variable changes in DNR systemic exposure.

Effects of piroxicam on prostaglandin E2 levels in rectal mucosa of adenomatous polyp patients: a randomized phase IIb trial

Prostaglandin E2 (PGE2) has served as a surrogate end point biomarker in colorectal tumor progression. Colonic mucosa PGE2 levels of patients with colorectal adenomas or carcinomas have been shown to be higher than in control subjects. Our dose-finding study on piroxicam, a nonsteroidal anti-inflammatory drug with chemopreventive effects in preclinical colon carcinoma models, suggested that 7.5 mg/day was well tolerated and associated with significant depression of rectal mucosa PGE2 concentrations in comparison with baseline values. We therefore conducted a randomized Phase IIb cancer prevention clinical trial to investigate the chemopreventive properties of piroxicam in patients with a history of resected colorectal adenomatous polyps. After a 2-month run-in period, 47 participants were randomized to piroxicam at a dose of 7.5 mg/day, and 49 were randomized to a placebo. Rectal biopsy specimens were taken at the initial visit, at 2 months later during the run-in period, and at 6, 12, and 24 months after the start of the interventions. Mean PGE2 concentrations in the rectal mucosa of the piroxicam-treated patients differed significantly between visits (P < 0.001), and the values at the 6-month visit (P < 0.001) and 12-month visit (P = 0.005) differed significantly from the average baseline value. Unfortunately, we observed an incidence of adverse gastrointestinal side effects in patients treated with 7.5 mg/day of piroxicam similar to that seen for arthritis patients treated with 20 mg/day. Consequently, the gastrointestinal toxicities appear to override the potential benefit that piroxicam may offer as a long-term colon cancer chemopreventive agent.

The effects of dietary selenomethionine on polyamines and azoxymethane-induced aberrant crypts

We evaluated the effects of dietary selenomethionine supplementation on colonic polyamine levels and the ability of L-selenomethionine supplementation to modulate the carcinogenic activity of azoxymethane (AOM) in the rat colon. Four-week-old male F344 rats were treated with 15 mg/kg body weight of AOM once a week for 2 weeks. Dietary selenomethionine at a concentration of either 1 or 2 ppm was administered in AIN-76A rodent diet to AOM-treated animals for 16 weeks. Aberrant crypt foci (ACF), precursor lesions of colon cancer, were investigated after the 16 week treatment course. Selenomethionine given in the diet at 2 ppm markedly reduced the number of aberrant crypt foci. The multiplicity of ACFs (i.e. the number of aberrant crypts/focus) and the percentage of microadenomas were also affected by selenomethionine in a dose dependent manner. However, evaluation of the colonic tissue polyamine levels between control and treated groups showed no significant difference. These results demonstrate that selenomethionine can modulate the development of AOM-induced premalignant lesions through a polyamine-independent mechanism.

Chromosome abnormalities in malignant melanoma: clinical significance of nonrandom chromosome abnormalities in 206 cases

We report the cytogenetic abnormalities from a series of 206 primary malignant melanoma specimens referred to a single institution. A total of 169 out of 206 unique cases had chromosome breakpoints. A previously described statistical method was used to detect nonrandom distribution of chromosome breakpoints at the level of chromosome regions. Nonrandom occurrence of chromosome breakpoints (indicating that the observed number of breaks significantly exceeded the expected number of breaks) was detected in 28 regions, suggesting a hierarchy of genetic abnormalities in melanoma. Clinical variables and tumor characteristics were analyzed for associations with the presence of any nonrandom chromosome breakpoints; with individual, nonrandomly involved chromosome regions; and with paired, nonrandomly involved chromosome regions. No nonrandomly involved chromosome regions or pairs of regions appeared to significantly affect survival. These results identify recurring, nonrandom chromosome abnormalities in malignant melanoma. These results suggest that recurring, nonrandom chromosome alterations play a key role in the etiology and/or progression of malignant melanoma and identify targets within the genome for molecular genetic studies.

SPECT imaging with the D(4) receptor antagonist L-750,667 in nonhuman primate brain

The suitability of an (123)I-labeled form of the putative D(4) receptor ligand L750,667 as a radiotracer for single photon emission computed tomography imaging was assessed in nonhuman primates. [(123)I]L750,667, labeled by iododestannylation, was administered to baboons in bolus and bolus plus constant infusion paradigms and imaged for 6 h. Total [(123)I]L750,667 brain uptake peaked (2.3% injected dose) at 15 min postinjection. [(123)I]L750,667 uptake was observed in all brain regions measured including diencephalon, brainstem, basal ganglia, cingulate cortex, and cerebellum, and slightly lower levels were noted in the frontal, parietal, temporoinsular, and occipital cortices. Administration of the D(4) receptor antagonist NGD 94-1 (2 mg/kg) did not displace radioactivity from any of the brain regions examined. Thus, while L750,667 is selective for the D(4) receptor in vitro, because brain [(123)I]L750,667 uptake was not displaced by NGD 94-1 at receptor saturating doses, [(123)I]L750,667 does not appear to be a suitable radiotracer for in vivo imaging of the D(4) receptor.

The NAD+ precursors, nicotinic acid and nicotinamide protect cells against apoptosis induced by a multiple stress inducer, deoxycholate

The bile salt, sodium deoxycholate (NaDOC), is a natural detergent that promotes digestion of fats. At high physiologic levels, NaDOC activates many stress-response pathways and induces apoptosis in various cell types. NaDOC induces DNA damage and activates poly(ADP-ribose) polymerase (PARP), an enzyme that utilizes NAD+ as a substrate to repair DNA. NaDOC also induces oxidative stress, endoplasmic reticulum (ER) stress and contributes to protein malfolding. The NAD+ precursors, nicotinic acid (NA) and nicotinamide (NAM) were found to protect cells against NaDOC-induced apoptosis. NA and NAM also decreased constitutive levels of both activated NF-kappaB and GRP78, two proteins that respond to oxidative stress. However, the mechanism by which NA and NAM protects cells against apoptosis does not involve a reduction in constitutive levels of oxidative stress. NA or NAM treatment increased the protein levels of glyceraldehyde-3-phosphate dehydrogense (GAPDH), a multi-functional enzyme, in the nucleus and cytoplasm, respectively. NAM did not activate the promoter/response elements of 13 stress response genes nor reduce intracellular non-protein thiols, suggesting that it is non-toxic to cells. NAM thus has promise as a dietary supplement to help prevent disorders involving excessive apoptosis.

Trichotillomania and the mourning process: a case report and review of the psychodynamics

We present our theory of trichotillomania (hair pulling) as a manic phenomenon, complementary to its classic comprehension as a mourning response. Under certain conditions, separation or threat of separation can generate sadness or grief, while in pathological cases, when the loss is experienced as unbearable, the response might be depressive or manic. We suggest that in trichotillomania (TR), like in mania, manic defenses are used to cope with separation. We believe hair pulling is an expression of primary magical thinking, offering the subject an illusion of control and victory over the object. A representative case of a young woman suffering from bipolar disorder with TR is described. Based on our case analysis, we argue that TR may not necessarily be a variant of OCD, but rather classified among the affective disorders.

Influence of health care, cost, and culture on breast cancer screening: issues facing urban American Indian women

BACKGROUND

Breast cancer is the second leading cause of cancer death among American Indian women. Southwestern American Indian women are more likely to have distant spread of the disease, and 5-year survival from breast cancer is poor in comparison to U.S. whites. Mortality from breast cancer could be reduced by more than 30% in American Indian women if current recommendations for screening were followed.

METHODS

A random household cross-sectional survey was conducted among 519 adult American Indian women in Phoenix, Arizona. Logistic regression was used to identify predictors of recent clinical breast examination and mammogram among those women aged 40 years and older.

RESULTS

Just more than half (53.0%) of the women surveyed reported they had received a clinical breast examination in the last year, and 35.7% indicated they had received a mammogram in the last 2 years. Access to care, knowledge of the examinations, and health beliefs were positively associated with breast cancer screening in the multivariate analyses.

CONCLUSIONS

The cancer screening rates observed in urban American Indian women are far below current national estimates and Healthy People 2000 Objectives. This study confirms the limited access of urban Indians to preventive health services, and supports a role for cancer education in improving screening participation in this special population.

Does Gustave Dax deserve to be forgotten? The temporal lobe theory and other contributions of an overlooked figure in the history of language and cerebral dominance

Gustave Dax played an important role in the early history of cerebral dominance for language. He not only sent the 1836 memoir of Marc Dax, his deceased father, to Paris in 1863, but saw to it that this important document was published before Paul Broca's own article on cerebral dominance appeared later in 1865. In addition, he supported his father's contention that the left hemisphere is special for speech with 140 additional clinical cases. Gustave Dax's own unique contribution, however, has been almost completely overlooked. Although his theory lacked specificity, he preceded Meynert, Schmidt, and Wernicke in suggesting that the left temporal lobe may be especially important for speech.

Chromosome abnormalities in ovarian adenocarcinoma: I. Nonrandom chromosome abnormalities from 244 cases

Cytogenetics provides important insights into the molecular pathogenesis of human cancers. Although extensive data exist on recurring cytogenetic abnormalities in hematologic cancers, data on individual solid tumor types remain limited. Previous studies of ovarian carcinoma indicated the presence of multiple, complex clonal chromosome abnormalities. Cytogenetics remains one of a few techniques capable of detecting these multiple, simultaneously occurring genetic abnormalities. We describe cytogenetic abnormalities from a series of 244 primary ovarian cancer specimens referred to a single institution. A total of 201/244 cases had fully characterized clonal chromosome abnormalities, of which 134 showed clonal chromosome breakpoints. We used a novel statistical technique to detect nonrandom chromosome breakpoints at the level of chromosome regions. Nonrandom occurrence of chromosome breakpoints was detected at regions 1p1*, 1q1*, 1p2*, 1q2*, 1p3*, 1q3, 3p1*, 1q4*, 6q1*, 6p2, 6q2, 7p1*, 7q1, 7p2*, 11p1*, 11q1, 11q2*, 12p1, 12q2*, 13p1, and 19q1. Simultaneous occurrence of multiple abnormalities was common. However, 120/134 cases had breakpoints at one or more of 13 commonly involved regions (*), suggesting a hierarchy of genetic abnormalities. Among clinical and tumor variables that predict patient survival, tumor grade was significantly associated with the presence of chromosome breakpoints. In additional studies, we show that nonrandom chromosome abnormalities are associated with impaired survival in ovarian cancer and that specific, nonrandomly involved chromosome regions retain significant effects on survival when analyses are controlled for important clinical variables. Additional specific chromosome abnormalities in this series are described, including chromosome gains and losses in near-diploid cases and homogeneously staining regions. These results suggest that recurring, nonrandom chromosome abnormalities are important in the pathogenesis and/or progression of ovarian cancers, and target areas of the genome for molecular genetic studies.

Physical activity, body mass index, and prostaglandin E2 levels in rectal mucosa

BACKGROUND

Evidence suggests a relationship between prostaglandin levels in colonic mucosa and risk of colon cancer. Physical inactivity and a higher body mass index (BMI; weight in kilograms divided by [height in meters]2) have been consistently shown to increase risk of this cancer. We investigated whether higher levels of leisure-time physical activity or a lower BMI was associated with lower concentrations of prostaglandin E2 (PGE2) in rectal mucosa.

METHODS

This study was conducted in 41 men and 22 women, 42-78 years of age, with a history of polyps, who participated in a randomized clinical trial testing the effects of piroxicam on rectal mucosal PGE2 levels. An [125I]PGE2 radioimmunoassay kit was used to determine PGE2 levels in samples of extracted rectal mucosa collected before randomization. Leisure-time physical activity was assessed through a self-administered questionnaire collected at baseline. The reported time spent at each activity per week was multiplied by its typical energy expenditure, expressed in metabolic equivalents (METs), to yield a MET-hours per week score. A repeated measures model was used to assess the effect of BMI and physical activity as predictors of PGE2 concentration. All statistical tests were two-sided.

RESULTS

After adjustment for age, a higher BMI was associated with higher PGE2 levels (P = .001). A higher level of leisure-time physical activity was inversely associated with PGE2 concentration (P<.03). An increase in BMI from 24.2 to 28.8 kg/m2 was associated with a 27% increase in PGE2. An increase in activity level from 5.2 to 27.7 MET-hours per week was associated with a 28% decrease in PGE2.

CONCLUSIONS

Physical activity and obesity may alter the risk of colon cancer through their effects on PGE2 synthesis.

Erythromycin-resistant Neisseria gonorrhoeae and oral commensal Neisseria spp. carry known rRNA methylase genes

Two Neisseria gonorrhoeae isolates from Seattle and two isolates from Uruguay were resistant to erythromycin (MIC, 4 to 16 microg/ml) and had reduced susceptibility to azithromycin (MIC, 1 to 4 microg/ml) due to the presence of the self-mobile rRNA methylase gene(s) ermF or ermB and ermF. The two Seattle isolates and one isolate from Uruguay were multiresistant, carrying either the 25.2-MDa tetM-containing plasmid (Seattle) or a beta-lactamase plasmid (Uruguay). Sixteen commensal Neisseria isolates (10 Neisseria perflava-N. sicca, 2 N. flava, and 4 N. mucosa) for which erythromycin MICs were 4 to 16 microg/ml were shown to carry one or more known rRNA methylase genes, including ermB, ermC, and/or ermF. Many of these isolates also were multiresistant and carried the tetM gene. This is the first time that a complete transposon or a complete conjugative transposon carrying an antibiotic resistance gene has been described for the genus Neisseria.

Enhancement of chemotherapy by manipulation of tumour pH

The extracellular (interstitial) pH (pHe) of solid tumours is significantly more acidic compared to normal tissues. In-vitro, low pH reduces the uptake of weakly basic chemotherapeutic drugs and, hence, reduces their cytotoxicity. This phenomenon has been postulated to contribute to a 'physiological' resistance to weakly basic drugs in vivo. Doxorubicin is a weak base chemotherapeutic agent that is commonly used in combination chemotherapy to clinically treat breast cancers. This report demonstrates that MCF-7 human breast cancer cells in vitro are more susceptible to doxorubicin toxicity at pH 7.4, compared to pH 6.8. Furthermore 31P-magnetic resonance spectroscopy (MRS) has shown that the pHe of MCF-7 human breast cancer xenografts can be effectively and significantly raised with sodium bicarbonate in drinking water. The bicarbonate-induced extracellular alkalinization leads to significant improvements in the therapeutic effectiveness of doxorubicin against MCF-7 xenografts in vivo. Although physiological resistance to weakly basic chemotherapeutics is well-documented in vitro and in theory, these data represent the first in vivo demonstration of this important phenomenon.

Chromosome abnormalities in ovarian adenocarcinoma: II. Prognostic impact of nonrandom chromosome abnormalities in 244 cases

In a large series of ovarian carcinomas from 244 patients, 134 cases had chromosome rearrangements. We showed before that the pattern of chromosome breakpoints involved 21 separate chromosome regions nonrandomly and, in 90% of cases with breaks, the breakpoints occurred within 13 commonly involved regions. Log-rank and proportional hazards regression analyses showed that the aggregate presence of a chromosome breakpoint in any of 21 nonrandomly involved regions and breaks in 9 distinct regions (1p1, 1q2, 1p3, 3p1, 6p2, 11p1, 11q1, 12q2, and 13p1) were associated with reduced patient survival. Breakpoints in other areas of the genome, including other nonrandomly involved regions, were not associated with decreased survival. Because many cases had breakpoints in more than one nonrandomly involved region, proportional hazards regression was also used to analyze for effects of each nonrandomly involved region, controlling for effects of other regions. With this approach, only breakpoints within 1p1 and 3p1 retained independent, deleterious effects on survival. Similarly, when nonrandomly involved regions were entered into a proportional hazards model containing clinical variables associated with altered patient survival (tumor grade, tumor stage, and residual disease > 1 cm after resection), only 1p1 (P = 0.007) and 3p1 (P = 0.04) were associated with independent, negative effects on survival. These studies demonstrate that chromosome breakpoints within specific, nonrandomly involved chromosome regions are associated with impaired survival in ovarian cancers. Regions 1p1 and 3p1 are identified as areas of particular significance and are appropriate targets for analytical techniques such as SAGE and microarray analysis.

Exploring the relationship between the person and the disorder among individuals hospitalized for psychosis

Recent research has suggested that people suffering from severe mental illness develop strategies to cope with their disorder. This study describes one specific strategy of coping with psychosis--through the use of narrative or a story. The report is based on bimonthly, semistructured research interviews conducted with 43 persons who were hospitalized for severe mental illness with psychotic features over a 1-year period. Qualitative analysis revealed five distinct categories, which seem to reflect different interactions between the participants' sense of self in relation to their illness. Narrative theory helped to identify subtleties in these interactions described by participants and conceptualize the categories. Conceptual and clinical implications of this process and future research opportunities are discussed.

Identification of four novel mutations in patients with carnitine palmitoyltransferase II (CPT II) deficiency

Carnitine palmitoyltransferase II (CPT II) deficiency, an autosomal recessive disorder of fatty-acid oxidation, presents as three distinct phenotypes (neonatal, infantile, and adult onset). In order to investigate the molecular basis of these three phenotypes, six patients with CPT II deficiency have been studied. All six unrelated patients in this study experienced the clinical symptoms of CPT II deficiency. Three patients had the neonatal form, one had the milder infantile form, and the remaining two had the adult-onset form with "muscular" symptoms only. Their diagnoses were based upon in vitro analysis of the mitochondrial beta-oxidation pathway in fibroblasts and standard enzyme assays. We devised a method to screen the entire coding sequence and flanking splice junction of the CPT II gene. A total of six different mutations have been identified, including four novel mutations. Among them, the previously reported common mutation, S113L, was only found in 3 of 12 variant alleles. Three of the six mutations have been identified in a few unrelated patients, while the remaining three have been found in single families. This study, as well as those by others, indicates genetic heterogeneity in this disease. In addition to tabulating the mutations, the correlation of mutant genotype to clinical phenotype is briefly discussed.

Inhibitory effect of selenomethionine on the growth of three selected human tumor cell lines

Selenium supplementation has been shown for many years to work as an anticarcinogenic agent both in epidemiology and in in vitro studies. Selenium supplementation has recently been shown to decrease total cancer incidence. However, the mechanism of action of selenium as an anticarcinogenic agent has yet to be elucidated. Selenomethionine was the predominant form of selenium in the dietary supplement in the study by Clark et al. (Clark, L.C., Combs, G.F., Turnbull, W.B., Slate, E.H., Chalker, D.K., Chow, J., Davis, L.S., Glover, R.A., Graham, G.F., Gross, E.G., Krongrad, A., Lesher, J.L., Park, H.K., Sanders, B.B., Smith, C.L., Taylor, J.R. and The Nutritional Prevention of Cancer Study Group (1996) Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin: a randomized controlled trial. J. Am. Med. Assoc., 276 (24), 1957-1963) and therefore we evaluated the growth inhibitory effects of selenomethionine against human tumor cells. Selenomethionine was tested against each of three human tumor cell lines (MCF-7/S breast carcinoma, DU-145 prostate cancer cells and UACC-375 melanoma) and against normal human diploid fibroblasts. All cell lines demonstrated a dose-dependent manner of growth inhibition by selenomethionine. Selenomethionine inhibited the growth of all of the human tumor cell lines in the micromolar (microM) range (ranging from 45 to 130 microM) while growth inhibition of normal diploid fibroblasts required 1 mM selenomethionine, approximately 1000-fold higher than for the cancer cell lines. In short, normal diploid fibroblasts were less sensitive than the cancer cell lines to the growth inhibitory effects of selenomethionine. Furthermore, we show that selenomethionine administration to these cancer cell lines results in apoptotic cell death and aberrant mitoses. These results demonstrate the differential sensitivity of tumor cells and normal cells to selenomethionine.

A novel mutation identified in carnitine palmitoyltransferase II deficiency

Carnitine palmitoyltransferase II (CPT II) deficiency is an autosomal recessive disorder of mitochondrial fatty-acid oxidation which presents as three distinct phenotypes (neonatal, infantile, and adult onset). CPT II exons from an adult-onset CPT II-deficient patient were amplified and directly sequenced to further investigate the molecular basis of this disorder. A novel mutation, C471T, in exon 4 of the carnitine palmitoyltransferase II gene was found which created a stop codon, TGA, at residue 124 of the protein (R124Stop). This mutation would result in severe protein truncation. This unique mutation was found on one allele while the S113L mutation, previously reported, was present on the other allele.

Catamenial pneumothorax heralding menarche in a 15-year-old adolescent

A case of spontaneous recurrent pneumothoraces (PTX) that has compelling features of a catamenial (CTM) origin is presented. A 15-year-old adolescent presented with a spontaneous PTX within 24 hours of menarche. A second PTX occurred one month later. While most cases of spontaneous PTX occur in male patients and are idiopathic, CTM PTX occur solely in menstruating female patients, have different treatment options, and recur with menses in the absence of appropriate therapy. Emergency practitioners should have a high clinical suspicion for CTM PTX in all female patients with spontaneous PTX, especially those which are recurrent or are associated with menstruation or menarche, in order to provide the patient with a complete spectrum of treatment plans.