Psilocybin and Other Classic Psychedelics in Depression

Psychedelic drugs such as psilocybin and ketamine are returning to clinical research and intervention across several disorders including the treatment of depression. This chapter focusses on psychedelics that specifically target the 5-HT2A receptor such as psilocybin and DMT. These produce plasma-concentration related psychological effects such as hallucinations and out of body experiences, insightful and emotional breakthroughs as well as mystical-type experiences. When coupled with psychological support, effects can produce a rapid improvement in mood among people with depression that can last for months. In this chapter, we summarise the scientific studies to date that explore the use of psychedelics in depressed individuals, highlighting key clinical, psychological and neuroimaging features of psychedelics that may account for their therapeutic effects. These include alterations in brain entropy that disrupt fixed negative ruminations, a period of post-treatment increased cognitive flexibility, and changes in self-referential psychological processes. Finally, we propose that the brain mechanisms underlying the therapeutic effect of serotonergic psychedelics might be distinct from those underlying classical serotonin reuptake-blocking antidepressants.

Mental and physical health in service member and veteran students who identify as American Indians and Alaskan natives

OBJECTIVE

The purpose of this study was to explore (a) current utilization rates of university mental health services among American Indian/Alaskan Native/Native Hawaiian (AI/AN/NH) student veterans and (b) predictors of mental health service utilization among AI/AN student veterans. Participants: Data for this cross-sectional study were obtained from the American College Health Association (ACHA)'s 2011-2014 National College Health Assessment II (n = 103). Methods: University mental health service utilization rates were calculated as a percentage for AI/AN/NH student veterans. Multivariable logistic regression was used to determine predictors of mental health service utilization. Results: Results showed that 14% of AI/AN/NH student veterans have used university mental health services. Predictors of mental health service utilization in this population included financial stress, lack of deployment during service, suicidal ideation, and a diagnosis of depression, model χ 2 (13) = 162. 128, p < 0.001, Nagelkerke R2 = 0.130. Conclusion: This research identified gaps in service provision for AI/AN service member and veteran students on college campuses and provided possible models for intervention development.

Small area estimation of human papillomavirus vaccination coverage among school-age children in Alabama counties

OBJECTIVES

This study estimated county-level human papillomavirus (HPV) vaccination initiation rates in Alabama and determined whether disparities existed between counties in the Mississippi Delta region (MDR) and Appalachian region (AR).

STUDY DESIGN

This study used an observational cross-sectional design.

METHODS

We used small area estimation methodology to estimate rates of medical provider-verified HPV vaccine initiation among school-age children in Alabama. Data for the study were retrieved from the 2015 National Immunization Survey (n = 22,205) and the US Census Bureau.

RESULTS

The predictive model results showed that older age (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.16, 1.29) was positively associated with vaccination initiation and black (OR = 0.79, 95% CI = 0.71, 0.87), white (OR = 0.56, 95% CI = 0.52, 0.60), and 'other' race/ethnicities (OR = 0.78, 95% CI = 0.70, 0.86), compared with Hispanics, and was negatively associated with vaccination initiation. The median (x̃)-modeled HPV vaccination initiation rate for all Alabama counties was 50.83% (interquartile range = 5.00%). Modeled HPV vaccination initiation rates were lowest in AR counties (x̃ = 49.81%), followed by counties not in the AR or MDR (x̃ = 53.26%) and MDR counties (x̃ = 54.90%).

CONCLUSIONS

Culturally sensitive school-based HPV vaccine delivery programs are needed for children living in AR counties in Alabama.

Identification of Caries Risk Determinants in Toddlers: Results of the GUSTO Birth Cohort Study

The aim of this study was to identify risk determinants leading to early childhood caries (ECC) and visible plaque (VP) in toddlers. Data for mother-child pairs participating in the Growing Up in Singapore towards Healthy Outcomes (GUSTO) birth cohort were collected from pregnancy to toddlerhood. Oral examinations were performed in 543 children during their clinic visit at 24 months to detect ECC and VP. Following logistic regression, ECC and VP were jointly regressed as primary and secondary outcomes, respectively, using the bivariate probit model. The ECC prevalence was 17.8% at 2 years of age, with 7.3% of children having a VP score >1. ECC was associated with nighttime breastfeeding (3 weeks) and biological factors, including Indian ethnicity (lower ECC rate), higher maternal childbearing age and existing health conditions, maternal plasma folate <6 ng/mL, child BMI, and the plaque index, while VP was associated with psychobehavioral factors, including the frequency of dental visits, brushing frequency, lower parental perceived importance of baby teeth, and weaning onto solids. Interestingly, although a higher frequency of dental visits and toothbrushing were associated with lower plaque accumulation, they were associated with increased ECC risk, suggesting that these established caries-risk factors may be a consequence rather than the cause of ECC. In conclusion, Indian toddlers may be less susceptible to ECC, compared to Chinese and Malay toddlers. The study also highlights a problem-driven utilization pattern of dental services (care sought for treatment) in Singapore, in contrast to the prevention-driven approach (care sought to prevent disease) in Western countries.

Preconception and pregnancy: opportunities to intervene to improve women's diets and lifestyles

Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a 'teachable moment' for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.

Greater access to fast-food outlets is associated with poorer bone health in young children

SUMMARY

A healthy diet positively influences childhood bone health, but how the food environment relates to bone development is unknown. Greater neighbourhood access to fast-food outlets was associated with lower bone mass among infants, while greater access to healthy speciality stores was associated with higher bone mass at 4 years.

INTRODUCTION

Identifying factors that contribute to optimal childhood bone development could help pinpoint strategies to improve long-term bone health. A healthy diet positively influences bone health from before birth and during childhood. This study addressed a gap in the literature by examining the relationship between residential neighbourhood food environment and bone mass in infants and children.

METHODS

One thousand one hundred and seven children participating in the Southampton Women's Survey, UK, underwent measurement of bone mineral density (BMD) and bone mineral content (BMC) at birth and 4 and/or 6 years by dual-energy X-ray absorptiometry (DXA). Cross-sectional observational data describing food outlets within the boundary of each participant's neighbourhood were used to derive three measures of the food environment: the counts of fast-food outlets, healthy speciality stores and supermarkets.

RESULTS

Neighbourhood exposure to fast-food outlets was associated with lower BMD in infancy (β = -0.23 (z-score): 95% CI -0.38, -0.08) and lower BMC after adjustment for bone area and confounding variables (β = -0.17 (z-score): 95% CI -0.32, -0.02). Increasing neighbourhood exposure to healthy speciality stores was associated with higher BMD at 4 and 6 years (β = 0.16(z-score): 95% CI 0.00, 0.32 and β = 0.13(z-score): 95% CI -0.01, 0.26 respectively). The relationship with BMC after adjustment for bone area and confounding variables was statistically significant at 4 years, but not at 6 years.

CONCLUSIONS

The neighbourhood food environment that pregnant mothers and young children are exposed may affect bone development during early childhood. If confirmed in future studies, action to reduce access to fast-food outlets could have benefits for childhood development and long-term bone health.

Micronutrients and oral clefts: a case-control study

Little is known about oral clefts in developing countries. We aimed to identify micronutrient-related and environmental risk factors for oral clefts in Thailand. We tested hypotheses that maternal exposure during the periconceptional period to multivitamins or liver consumption would decrease cleft lip with or without cleft palate (CL ± P) risk and that menstrual regulation supplements would increase CL ± P risk. We conducted a multisite hospital-based case-control study in Thailand. We enrolled cases with CL ± P and 2 live births as controls at birth from the same hospital. Mothers completed a questionnaire. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Eighty-six cases and 172 controls were enrolled. Mothers who took a vitamin (adjusted OR, 0.39; 95% CI: 0.16, 0.94) or ate liver (adjusted OR, 0.26; 95% CI: 0.12, 0.57) were less likely than those who did not to have an affected child. Mothers who took a menstrual regulation supplement were more likely than mothers who did not to have an affected child. Findings did not differ for infants with a family history of other anomalies or with isolated CL ± P. If replicated, our finding that liver decreases CL ± P risk could offer a low-cost primary prevention strategy.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS)

OBJECTIVE

To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound.

METHODS

This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated.

RESULTS

Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed.

CONCLUSION

Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Occupational physical activities, working hours and outcome of pregnancy: findings from the Southampton Women's Survey

OBJECTIVES

To investigate risks of physical activity at work by pregnancy trimester, including the effects on head and abdominal circumference.

METHOD

At 34 weeks of gestation we interviewed 1327 mothers from the prospective Southampton Women's Survey (SWS); we asked about their activities (working hours, standing/walking, kneeling/squatting, trunk bending, lifting and night shifts) in jobs held at each of 11, 19 and 34 weeks of gestation, and subsequently ascertained four birth outcomes (preterm delivery, small for gestational age (SGA) and reduced head or abdominal circumference) blinded to employment history.

RESULTS

Risk of preterm delivery was elevated nearly threefold in women whose work at 34 weeks entailed trunk bending for >1 h/day. Small head circumference was more common in babies born to women who worked for >40 h/week. However, no statistically significant associations were found with SGA or small abdominal circumference, and preterm delivery showed little association with long working hours, lifting, standing or shift work.

CONCLUSIONS

There is a need for more research on trunk bending late in pregnancy, and on the relationship of work to reduced head circumference. Our findings on several other occupational exposures common among pregnant workers are reassuring.

Comparison of pre-treatment CYFRA 21 – 1 and SCC-Antigen assay in primary cervical carcinoma – a preliminary report

CYFRA21 - 1, a fragment of cytokeratin19, has been widely assessed as a serum marker of squamous malignancies. Previous studies using CYFRA21 - 1 and SCC-Antigen have shown mixed results but have indicated a better predictive prognostic value for SCC-Ag as compared to CYFRA21-1. The aim of our prospective, observational, pilot study was to evaluate the role of CYFRA21-1 and SCC-Ag in primary cervical carcinoma. Pre-operative serum CYFRA21-1 and SCC-Ag were measured (n = 14) in women with cervical carcinoma and correlated with staging, clinico-pathological parameters and prognostic data. Logistic regression analysis with CYFRA 21 - 1 test status (positive or negative) as a dependent variable showed that nodal metastases (p = 0.001) and lymphovascular space invasion (LVSI) (p = 0.005) were significant predictors, whereas stage and SCC-Ag levels were not significant. There was also no statistically significant correlation between SCC-Ag and CYFRA21-1 levels. If larger studies confirm these preliminary results, the option of laparoscopic surgical staging in patients with raised CYFRA21-1 levels could be considered.

A longitudinal study of blood folate levels and depressive symptoms among young women in the Southampton Women's Survey

BACKGROUND

Lower blood folate levels have been associated with depression in cross-sectional surveys, but no studies have examined the relationship prospectively to determine whether the relationship is causal. A follow-up study was designed to examine whether lower blood folate levels predict incident depressive symptoms.

METHOD

Women aged 20-34 years registered in general practices in Southampton, UK, were asked to participate. Baseline assessment included the general health questionnaire (GHQ-12) measure of anxiety and depression, and socioeconomic factors, diet, smoking and alcohol intake. Two years later, participants' general practice (GP) records were examined for evidence of incident symptoms of depression.

RESULTS

At baseline, 5051 women completed the GHQ-12 and had red cell folate levels measured, of whom 1588 (31.4%) scored above the threshold for case level symptoms of anxiety and depression on the GHQ-12. Two years later, GP records for 3996 (79.1%) were examined, but 1264 with baseline evidence of depression were excluded from follow-up analysis. Incident depressive symptoms were recorded for 307 (11.2%) of the remaining 2732. Lower red cell folate levels were associated with caseness on the GHQ-12 (adjusted prevalence ratio 0.99 per 100 nmol/l red cell folate, 95% CI 0.98 to 1.00). No relationship was found between red cell folate levels and incident depressive symptoms over 2 years (adjusted hazard ratio 1.00, 95% CI 0.97 to 1.03).

CONCLUSIONS

Low folate levels were not associated with subsequent depressive symptoms. This suggests that lower blood folate levels may be a consequence rather than a cause of depressive symptoms.

Conservative surgical management of small-volume stage IB1 cervical cancer

OBJECTIVE

To determine outcomes of women with small-volume stage IB1 disease managed by conservative surgical treatment.

DESIGN

A retrospective review.

SETTING

The Northern Gynaecological Oncology Center, Queen Elizabeth Hospital, Gateshead, UK.

POPULATION

Women with stage IB1 cervical cancer who were managed by conservative surgery over a 6-year period between 1 January 2000 and 31 December 2005.

MAIN OUTCOME MEASURES

Pelvic lymph node metastases, recurrence rates and outcome survival.

RESULTS

A total of 17 women with conservatively managed stage IB1 cervical cancer were identified. Their ages were 25-67 years, median 37 years, 4 women were nulliparous. All women presented with an abnormal screening smear showing at least severe dyskaryosis. Estimated tumour volumes ranged from 16 to 640 mm3, median 72 mm3. Four women showed multifocal invasion. All four nulliparous women and one parous woman underwent fertility-sparing treatment, i.e. loop cone +/- laparoscopic pelvic node dissection. The other 12 women underwent laparoscopic assisted vaginal hysterectomy/total abdominal hysterectomy +/- pelvic lymph node dissection. There were no cases of residual disease in any of the definitive treatment specimens. There were no cases of metastatic spread to pelvic lymph nodes. To date, no women have developed recurrent disease, and all women are alive and well (median follow up, 29 months).

CONCLUSIONS

The conservative surgical management of small-volume stage IB1 cases in this series showed an excellent outcome with no cases showing pelvic lymph node involvement and no cases developing recurrent disease. A more formal assessment of tumour volume with a more active approach to determining the third dimension will allow more women the option of conservative treatment, thereby minimising the adverse effects of radical surgery.

The effect of epithelial and stromal tumor components on FIGO stages III and IV ovarian carcinosarcomas treated with primary surgery and chemotherapy

The aim of this study is to assess the effect of epithelial and stromal tumor components on survival outcomes in FIGO stage III or IV ovarian carcinosarcomas (OCS) treated with primary surgery and adjuvant chemotherapy at the Northern Gynaecological Oncology Centre (NGOC), Gateshead. Women were identified from the histopathology/NGOC databases. Age, FIGO stage, details of histology, treatment, and overall survival were recorded. Of 34 cases (1994-2006, all FIGO stages), 17 were treated with primary surgery followed by adjuvant chemotherapy for FIGO stage III or IV. The median age was 66 years (52-85 years). Cytoreduction was optimal (n= 9) or complete (n= 1) in 10/17 (59%) cases. Epithelial predominant (EP) or stromal predominant (SP) tumor (defined as >50% of either component in the primary tumor) was noted in 12 and 5 cases, respectively. Epithelial types included serous (n= 9), endometrioid (n= 5), and mixed types (n= 3). Twelve women have died of disease. The median overall survival was 11.0 months (3-74 months). On univariate analysis, survival was not affected by optimal/suboptimal debulking, platinum/doxorubicin-containing chemotherapy, or homologous/heterologous stromal components. Stromal components (>25%) adversely affected survival (P= 0.02), and there was a trend to worse survival with serous compared with nonserous epithelial components (P= 0.07). Cox regression (multivariate analysis) showed that SP tumors (P= 0.04), suboptimal debulking (P= 0.01), age (P= 0.01), and tumors with serous epithelial component (P= 0.05) were adverse independent prognostic factors. Type of chemotherapy and homologous/heterologous components (P= 0.24) did not affect overall survival. In conclusion, our study suggests that SP-OCS have a worse survival outcome than EP tumors. Tumors with serous epithelial components adversely affected the survival compared with nonserous components. Larger studies are required to confirm these effects and to identify the optimum chemotherapy regimen for OCS.

A randomized phase II trial of indole-3-carbinol in the treatment of vulvar intraepithelial neoplasia

The aim of this study was to determine the potential therapeutic benefits of indole-3-carbinol (I3C) in the management of vulvar intraepithelial neoplasia (VIN). Women with histologically confirmed high-grade VIN were randomized to receive 200 and 400 mg/day of I3C. Symptomatology by visual analog scale and vulvoscopic appearance were assessed at recruitment, 6 weeks, 3 months, and 6 months. Tissue biopsy to determine histologic response was obtained at completion of the study period. Urine samples were obtained at each visit to determine 2-hydroxyestrone to 16-alpha-hydroxyestrone ratios. Data from 12 women were suitable for analysis. There was a significant improvement in symptomatology with the introduction of I3C (itch, P= 0.018; pain, P= 0.028). Lesion size and severity were also significantly reduced (size, P= 0.005; appearance, P= 0.046). In addition, there was a significant increase in 2-hydroxyestrone to 16-alpha-hydroxyestrone ratio following commencement of I3C, P= 0.05. However, tissue biopsy from the worst-affected vulval areas revealed no improvement in grade of VIN during the 6-month period, P= 0.317. There were no significant differences in results between those women taking 200 mg/day of I3C and those on 400 mg/day. This study has shown significant clinical improvement in symptomatology and vulvoscopic appearance of VIN with I3C therapy. Further clinical and scientific investigations are required to support these preliminary findings.

"True" versus "apparent" stage I epithelial ovarian cancer: value of frozen section analysis

The aim of this prospective study was to determine the clinical benefits of introducing peroperative frozen section analysis into the surgical management policy of women referred with an adnexal mass suspicious of ovarian cancer. All women surgically managed at the Northern Gynaecological Oncology Centre, Gateshead, UK, between July 1, 2002, and June 30, 2003, where frozen section analysis had been utilized were included for analysis. Correlation was determined between cases surgically staged following the frozen section result and the clinical need for staging based on the pathologic diagnosis from the paraffin section. During the 12-month period, 130 women underwent frozen section analysis. Paraffin section diagnoses included 74 benign tumors, 11 borderline tumors, 34 primary epithelial cancers, 5 nonepithelial cancers, and 6 metastatic tumors. All primary epithelial ovarian cancers were correctly identified as requiring a staging procedure based on the frozen section result. Four of seventy-four cases reported as benign on frozen section analysis were underdiagnosed; two were later diagnosed on paraffin section as borderline tumors and a further two as malignant (one low-grade adenosarcoma and one primary peritoneal cancer). Of the 130 cases, 55 (42.3%) underwent a staging procedure based on the frozen section result. The value of frozen section analysis in determining the need for the performance of a staging procedure had the following statistical test results: sensitivity = 92%, specificity = 88%, positive predictive value = 82%, and negative predictive value = 95%. Excluding the borderline tumors, metastatic tumors, and primary peritoneal tumor where staging did not impact subsequent clinical management, the statistical test results for frozen section analysis in determining the need for a staging procedure were sensitivity = 97%, specificity = 95%, positive predictive value = 90%, and negative predictive value = 99%. The clinical benefits of introducing frozen section analysis in the surgical staging policy of women with an adnexal mass suspicious of ovarian malignancy included avoidance of a surgical staging procedure in 95% of cases identified on paraffin section analysis to be benign. This benefit was without compromising the avoidance of chemotherapy in true stage I epithelial ovarian cancer cases. Additional benefits included the confirmation of malignancy where extraovarian lesions were suggestive but not indicative of malignant disease, and the intraoperative identification of metastatic disease of nonovarian origin.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called "risk of malignancy index" (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

Effects of low-level laser therapy on the rate of orthodontic tooth movement

OBJECTIVES

To test the hypothesis that mechanical forces combined with low-level laser therapy stimulate the rate of orthodontic tooth movement.

STUDY DESIGN

This study was a double blind, randomized placebo/control matched pairs clinical trial to test the efficacy of GaAlAs low-level laser therapy (LLLT) on 12 young adult patients who required retraction of maxillary canines into first premolar extraction spaces using tension coil springs with fixed edgewise appliance. LLLT was applied on the mucosa buccally, distally and palatally to the canine on the test side and using a pseudo-application on the placebo side. Dental impressions and casts were made at the commencement of the trial and at the end of the first, second and third months after starting the trial. Measurement of tooth movements was made on each stage model using a stereo microscope.

RESULTS

There was no significant difference of means of the canine distal movement between the LLLT side and the placebo side for any time periods (p-value = 0.77).

CONCLUSION

The energy density of LLLT (GaAlAs) at the surface level in this study (25 J/cm(2)) was probably too low to express either stimulatory effect or inhibitory effect on the rate of orthodontic tooth movement.

Risk of malignancy index for referral of ovarian cancer cases to a tertiary center: does it identify the correct cases?

Characterization of adnexal masses to identify patients with malignant ovarian tumors preoperatively for referral to a cancer center for treatment has been extensively studied. A simple algorithm called “risk of malignancy index” (RMI) reported by Jacobs incorporated the serum CA125 level, menopausal status, and ultrasound morphologic features. This algorithm has subsequently been tested on retrospective and prospective data with encouraging results. However, these studies did not include cases that had had both their serum CA125 measurements and ultrasound examinations from a diverse range of laboratories and sonographers. The purpose of this study was to determine the effectiveness of the RMI algorithm for identifying cases of ovarian malignancy presenting at cancer units for subsequent referral to a cancer center. All cases of suspected ovarian malignancy referred to the Northern Gynaecological Oncology Centre (NGOC) during an 18-month period were identified from the NGOC database. A case note review was performed, and the following data were extracted: patient demographics, the referring physician and the operating surgeon, ultrasound morphology, serum CA125 levels, and menopausal status. All patients had their ultrasound performed by sonographers at the peripheral unit according to local protocols. A total of 182 patients with a pelvic mass were referred to the center for surgery. A total of 24% patients had benign tumors, 6% had tumors of borderline malignancy, and 70% had invasive tumors. A total of 145 cases had an RMI >200; 125 of these had ovarian or peritoneal cancers. An RMI >200 had a sensitivity of 88.5% for diagnosing invasive lesions. The overall sensitivity of this algorithm for diagnosing all borderline, invasive ovarian, or primary peritoneal lesions was 87.4%, and the positive predictive value was 86.8%. Our data confirm the effectiveness of the RMI algorithm in clinical practice for the identification and subsequent referral to cancer centers of cases of potential ovarian malignancy. We therefore recommend its continued use.

“True” versus “apparent” stage I epithelial ovarian cancer: value of frozen section analysis

The aim of this prospective study was to determine the clinical benefits of introducing peroperative frozen section analysis into the surgical management policy of women referred with an adnexal mass suspicious of ovarian cancer. All women surgically managed at the Northern Gynaecological Oncology Centre, Gateshead, UK, between July 1, 2002, and June 30, 2003, where frozen section analysis had been utilized were included for analysis. Correlation was determined between cases surgically staged following the frozen section result and the clinical need for staging based on the pathologic diagnosis from the paraffin section. During the 12-month period, 130 women underwent frozen section analysis. Paraffin section diagnoses included 74 benign tumors, 11 borderline tumors, 34 primary epithelial cancers, 5 nonepithelial cancers, and 6 metastatic tumors. All primary epithelial ovarian cancers were correctly identified as requiring a staging procedure based on the frozen section result. Four of seventy-four cases reported as benign on frozen section analysis were underdiagnosed; two were later diagnosed on paraffin section as borderline tumors and a further two as malignant (one low-grade adenosarcoma and one primary peritoneal cancer). Of the 130 cases, 55 (42.3%) underwent a staging procedure based on the frozen section result. The value of frozen section analysis in determining the need for the performance of a staging procedure had the following statistical test results: sensitivity = 92%, specificity = 88%, positive predictive value = 82%, and negative predictive value = 95%. Excluding the borderline tumors, metastatic tumors, and primary peritoneal tumor where staging did not impact subsequent clinical management, the statistical test results for frozen section analysis in determining the need for a staging procedure were sensitivity = 97%, specificity = 95%, positive predictive value = 90%, and negative predictive value = 99%. The clinical benefits of introducing frozen section analysis in the surgical staging policy of women with an adnexal mass suspicious of ovarian malignancy included avoidance of a surgical staging procedure in 95% of cases identified on paraffin section analysis to be benign. This benefit was without compromising the avoidance of chemotherapy in true stage I epithelial ovarian cancer cases. Additional benefits included the confirmation of malignancy where extraovarian lesions were suggestive but not indicative of malignant disease, and the intraoperative identification of metastatic disease of nonovarian origin.

Portal and umbilical venous blood supply to the liver in the human fetus near term

OBJECTIVES

To determine the contribution of the umbilical (UV) and portal (PV) veins to blood supply to the human fetal liver in a low-risk population near term, and to assess the distribution between the left and right lobes.

METHODS

In 91 low-risk pregnancies with normally grown fetuses at 36 weeks of gestation we measured the distribution of blood in the UV and PV to the right and left hepatic lobes using ultrasound imaging and Doppler techniques.

RESULTS

The median (10(th), 90(th) centile) total UV return was 205 (127, 294) mL/min, of which 25% (13, 47%) was shunted through the ductus venosus, 55% (35, 66%) was distributed to the left hepatic lobe, and 20% (11, 30%) was distributed to the right hepatic lobe. While the left lobe was supplied exclusively by the UV, the right lobe received 50% (20, 70%; 37 (16, 65) mL/min) of its venous blood supply from the PV. The total venous blood supply to the liver parenchyma was 185 (114, 277) mL/min; 21% (8, 34%) came from the PV supply to the right lobe and the remainder came from the UV supply to both lobes.

CONCLUSIONS

The venous supply to the left lobe is from nutrient-rich UV blood; for the right lobe, half is from UV blood and half from nutrient-poor PV blood. This watershed between the portal and umbilical venous flows to the fetal liver suggests a corresponding functional dichotomy; this may be modified by hemodynamic influences, with long-term consequences.

Doppler blood flow velocity waveforms in the fetal renal arteries: variability at proximal and distal sites in the right and left arteries

OBJECTIVE

To investigate variability in pulsatility/resistance indices and absolute velocities of blood flow in fetal renal arteries dependent on side and sampling site within each vessel.

METHODS

Doppler blood flow measurements of pulsatility index (PI), resistance index (RI) and peak systolic velocity (PSV) and end-diastolic velocity (EDV) were performed in the renal arteries of 27 fetuses between 236 and 247 days of gestation. Velocity waveforms were sampled in both the right and left renal arteries at two different sites: proximally, close to the aorta, and distally, before any major visible bifurcation of the vessels. The intraobserver variation was measured in 15 additional fetuses.

RESULTS

Mean values of PI and RI were similar in the right and left renal arteries and at the proximal and distal sampling sites of these arteries. Mean PSV and EDV were higher at the proximal compared to the distal site on both sides. For all parameters the 95% limits of agreement between measurements made in the right and left arteries and at proximal and distal sites were wide but tended to be narrower for the left renal artery and at the distal site. Intraclass correlation coefficients for intraobserver variability were 0.88, 0.89, 0.83 and 0.81 for PI, RI, PSV and EDV, respectively.

CONCLUSIONS

It is important to standardize the precise site at which Doppler blood flow velocity waveform measurements are made in the renal arteries of the fetus. On the basis of our observations, we suggest that the left renal artery is the preferred vessel for sampling and that measurements should be made in the renal arterial trunk away from the aorta and before any visible branches.

Neonatal bone mass: influence of parental birthweight, maternal smoking, body composition, and activity during pregnancy

Evidence is accumulating that intrauterine growth and development may influence an individual's risk of osteoporosis in later adult life. To examine maternal and paternal influences on intrauterine skeletal growth, we used dual-energy X-ray absorptiometry to measure the neonatal bone mineral content (BMC) and bone mineral density (BMD) of 145 infants born at term. Independently of the infant's duration of gestation at birth, the birthweights of both parents and the height of the father were positively correlated with neonatal whole body BMC. Women who smoked during pregnancy had infants with a lower whole body BMC and BMD; overall, there was a 7.1-g (11%) average difference between whole body BMC of infants whose mothers did and did not smoke during pregnancy (p = 0.005). Women with thinner triceps skinfold thicknesses (reflecting lower fat stores) and those who reported a faster walking pace and more frequent vigorous activity in late pregnancy also tended to have infants with a lower BMC and BMD (p values for BMC; 0.02, 0.03, and 0.05, respectively). Maternal thinness and faster walking pace but not maternal smoking or parental birthweight also were associated with lower bone mineral apparent density (BMAD). The influences on skeletal growth and mineralization were independent of placental weight, a marker of the placental capacity to deliver nutrients to the fetus. These observations point to a combination of genetic and intrauterine environmental influences on prenatal skeletal development and suggest that environmental modulation, even at this early stage of life, may reduce the risk of osteoporosis in adulthood.