Reproductive healthcare in adolescents with autism and other developmental disabilities

BACKGROUND

Adults with developmental disabilities often have less access to reproductive health services than adults without these disabilities. However, little is known about how adolescents with developmental disabilities, including autism, access reproductive healthcare.

OBJECTIVE

We aimed to characterize the use of reproductive healthcare services among adolescents with autism and those with other developmental disabilities in comparison with adolescents with typical development.

STUDY DESIGN

We conducted a cohort study of a sample of adolescents who were continuously enrolled members of Kaiser Permanente Northern California, an integrated healthcare system, from ages 14 to 18 years. The final analytical sample included 700 adolescents with autism, 836 adolescents with other developmental disabilities, and 2187 typically developing adolescents who sought care between 2000 and 2017. Using the electronic health record, we obtained information on menstrual conditions, the use of obstetrical-gynecologic care, and prescriptions of hormonal contraception. We compared healthcare use between the groups using chi-square tests and covariate-adjusted risk ratios estimated using modified Poisson regression.

RESULTS

Adolescents with autism and those with other developmental disabilities were significantly more likely to have diagnoses of menstrual disorders, polycystic ovary syndrome, and premenstrual syndrome than typically developing adolescents. These 2 groups also were less likely than typically developing peers to visit the obstetrician-gynecologist or to use any form of hormonal contraception, including oral contraception, hormonal implants, and intrauterine devices. Adolescents in all 3 groups accessed hormonal contraception most frequently through their primary care provider, followed by an obstetrician-gynecologist.

CONCLUSION

Adolescents with autism and those with other developmental disabilities are less likely than their typically developing peers to visit the obstetrician-gynecologist and to use hormonal contraception, suggesting possible care disparities that may persist into adulthood. Efforts to improve access to reproductive healthcare in these populations should target care delivered in both the pediatric and obstetrics-gynecology settings.

Newborn vitamin D levels in relation to autism spectrum disorders and intellectual disability: A case-control study in california

Vitamin D deficiency has been increasing concurrently with prevalence of autism spectrum disorders (ASD), and emerging evidence suggests vitamin D is involved in brain development. Most prior studies of ASD examined vitamin D levels in children already diagnosed, but a few examined levels during perinatal development, the more likely susceptibility period. Therefore, we examined newborn vitamin D levels in a case-control study conducted among births in 2000-2003 in southern California. Children with ASD (N = 563) or intellectual disability (ID) (N = 190) were identified from the Department of Developmental Services and compared to population controls (N = 436) identified from birth certificates. 25-hydroxyvitamin D (25(OH)D) was measured in archived newborn dried blood spots by a sensitive assay and corrected to sera equivalents. We categorized 25(OH) D levels as deficient (<50 nmol/L), insufficient (50-74 nmol/L), and sufficient (≥75 nmol/L), and also examined continuous levels, using logistic regression. The adjusted odds ratios (AOR) and 95% confidence intervals for ASD were 0.96 (0.64-1.4) for 25(OH)D deficiency (14% of newborns) and 1.2 (0.86-1.6) for insufficiency (26% of newborns). The AORs for continuous 25(OH)D (per 25 nmol/L) were 1.0 (0.91-1.09) for ASD and 1.14 (1.0-1.30) for ID. Thus, in this relatively large study of measured newborn vitamin D levels, our results do not support the hypothesis of lower 25(OH)D being associated with higher risk of ASD (or ID), although we observed suggestion of interactions with sex and race/ethnicity. 25(OH)D levels were relatively high (median 84 nmol/L in controls), so results may differ in populations with higher prevalence of low vitamin D levels. Autism Res 2019, 12: 989-998. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We studied whether vitamin D levels measured at birth were related to whether a child later developed autism (or low IQ). Our results did not show that children with autism, or low IQ, overall had lower vitamin D levels at birth than children without autism. Vitamin D levels were fairly high, on average, in these children born in Southern California.

A Report of the Histological Features in 12 Cases of Gonadoblastoma

This report deals with 12 cases of gonadoblastoma submitted to the Ovarian Tumour Panel of the Royal College of Obstetricians and Gynaecologists. These tumours are found in children and young adults. Children may present with obvious genital malformation, retarded growth or precocious puberty. In adults the main complaint is amenorrhoea but sometimes there is associated masculinization. Histologically the gonadoblastoma has a distinctive structure, easily recognized in most instances. The most important feature is the instability of the germ cells in these tumours. Nine of these cases showed an associated dysgerminoma, bilateral in 4. In any cases of suspected gonadal dysgenesis presumptive evidence of diagnosis is suggested by the presence of a Y chromosome, raised gonadotrophin output and pelvic calcification on X-ray examination. At operation, streak tissue on both sides must be removed since these tumours are frequently microscopic in size. For the same reason the tissue removed should be serially sectioned.

Prenatal and Newborn Immunoglobulin Levels from Mother-Child Pairs and Risk of Autism Spectrum Disorders

Background: An etiological role for immune factors operating during early brain development in children with autism spectrum disorders (ASD) has not yet been established. A major obstacle has been the lack of early biologic specimens that can be linked to later diagnosis. In a prior study, we found lower risk of ASD associated with higher levels of maternally-derived total IgG and Toxoplasmosis gondii (Toxo) IgG in newborn blood spot specimens from children later diagnosed with ASD compared to population controls.

Methods: We obtained maternal mid-gestational serum specimens and newborn screening blood spots from the California Genetics Disease Screening Program (GDSP) for linked mother-baby pairs for 84 children with ASD and 49 children with developmental delay but not ASD (DD) identified from California Department of Developmental Services records and for 159 population controls sampled from birth certificates.Immunoglobulin levels in maternal and newborn specimens were measured by solid phase immunoassays and analyzed in logistic regression models for total IgG, total IgM, and Toxo IgG, and, for maternal specimens only, Toxo IgM. Correlations between maternal and newborn ranked values were evaluated.

Results: In both maternal and newborn specimens, we found significantly lower risk of ASD associated with higher levels of Toxo IgG. In addition, point estimates for all comparisons were < 1.0 suggesting an overall pattern of lower immunoglobulin levels associated with higher ASD risk but most did not reach statistical significance. We did not find differences in maternal or newborn specimens comparing children with DD to controls.

Discussion: These results are consistent with evidence from our prior study and other published reports indicating that immune factors during early neurodevelopment may be etiologically relevant to ASD. Lowered immunoglobulin levels may represent suboptimal function of the maternal immune system or reduced maternal exposure to common infectious agents.

Conclusion: Patterns seen in these selected immunoglobulins may provide clues to mechanisms of early abnormalities in neurodevelopment contributing to ASD. We recommend further study of immunoglobulin profiles in larger samples of linked mother-baby pairs to evaluate possible etiologic relevance.

Autism and developmental screening in a public, primary care setting primarily serving Hispanics: challenges and results

We implemented screening of children 16-30 months of age (n = 1,760) from a typically under-served, primarily Hispanic, population, at routine pediatric appointments using the modified checklist for autism in toddlers (M-CHAT) and Ages and Stages Questionnaire. Screen positive rates of 26 and 39%, respectively, were higher than previous reports. Hispanics were more likely to score M-CHAT positive than non-Hispanics (adjusted OR 1.7, 95% CI 1.2-2.4), as were those screened in Spanish. About 30% of screen-positive children were referred for further assessment, but only half were seen. Thus screening in this population is feasible, but may require additional resources. Attention to the cultural applicability of screening instruments, as well as to explaining the results or need for additional services to parents, is critical to serve the growing Hispanic population.

Adaptation of the "ten questions" to screen for autism and other neurodevelopmental disorders in Uganda

Neurodevelopmental disorders are recognized to be relatively common in developing countries but little data exist for planning effective prevention and intervention strategies. In particular, data on autism spectrum disorders are lacking. For application in Uganda, we developed a 23-question screener (23Q) that includes the Ten Questions screener and additional questions on autism spectrum disorder behaviors. We then conducted household screening of 1169 children, 2-9 years of age, followed by clinical assessment of children who screened positive and a sample of those who screened negative to evaluate the validity of the screener. We found that 320 children (27% of the total) screened positive and 68 children received a clinical diagnosis of one or more moderate to severe neurodevelopmental disorders (autism spectrum disorder; cerebral palsy; epilepsy; cognitive, speech and language, hearing, or vision impairment), including 8 children with autism spectrum disorders. Prevalence and validity of the screener were evaluated under different statistical assumptions. Sensitivity of the 23Q ranged from 0.55 to 0.80 and prevalence for ≥1 neurodevelopmental disorders from 7.7/100 children to 12.8/100 children depending on which assumptions were used. The combination of screening positive on both autism spectrum disorders and Ten Questions items was modestly successful in identifying a subgroup of children at especially high risk of autism spectrum disorders. We recommend that autism spectrum disorders and related behavioral disorders be included in studies of neurodevelopmental disorders in low-resource settings to obtain essential data for planning local and global public health responses.

Birth prevalence of autism spectrum disorders in the San Francisco Bay area by demographic and ascertainment source characteristics

Using standardized methods for multi-source surveillance, we calculated the prevalence of autism spectrum disorders (ASD) among children born in a racially diverse region in 1994 or 1996 as 4.7/1000 live births. Children with ASD before age 9 were identified through chart abstraction at health-related sources; three-quarters were being served by the state-wide Department of Developmental Services. In adjusted models, we found a male:female ratio of 6:1, a doubling of ASD prevalence among children of older mothers (40+), and lower prevalence with lower paternal education. Children of Black or Hispanic mothers had lower prevalence than those of White, non-Hispanic mothers, but these differences were attenuated after adjustment. Prevalence in children of Asian mothers was similar to Whites. Potential under-counting is discussed.

Neonatally measured immunoglobulins and risk of autism

Previous studies indicate that prenatal exposure to infections is a possible pathway through which autism spectrum disorders (ASD) could be initiated. We investigated whether immunoglobulin levels in archived specimens obtained from newborns subsequently diagnosed with ASD are different from levels in newborn specimens from controls. Children with ASD born in six California counties in 1994 were ascertained through records of the California Department of Developmental Services (DDS) and Kaiser Permanente; controls were randomly selected using birth certificates. Archived newborn blood specimens were obtained from the California Genetic Disease Screening Program (GDSP) for N = 213 cases and N = 265 controls and assayed to determine levels of total IgG, antigen-specific IgG to selected common pathogens, total IgM, total IgA, and C-reactive protein (CRP). We did not find measurable levels of total IgM or IgA in any neonate and measurable CRP was present in only a few. No antigen-specific IgG antibodies were elevated in cases compared to controls and total IgG levels were lower. In adjusted models, a 10-unit increase in total IgG yielded an OR = 0.72 (95% CI 0.56, 0.91); a significantly decreasing trend in risk of ASD was observed across increasing exposure quartiles of total IgG (P = 0.01). The finding of lower IgG in cases may indicate maternal immune dysfunction during gestation and/or impaired transplacental transfer of immunoglobulins. Further investigation of IgG levels in newborns and the mechanisms by which they might be associated with ASD are warranted.

Behavioral adaptation to fixed-interval and fixed-time food delivery in golden hamsters

Food-deprived golden hamsters in a large enclosure received food every 30 sec contingent on lever pressing, or free while their behavior was continuously recorded in terms of an exhaustive classification of motor patterns. As with other species in other situations, behavior became organized into two main classes. One (terminal behaviors) increased in probability throughout interfood intervals; the other (interim behaviors) peaked earlier in interfood intervals. Which class an activity belonged to was independent of whether food was contingent on lever pressing. When food was omitted on some of the intervals (thwarting), the terminal activities began sooner in the next interval, and different interim activities changed in different ways. The interim activities did not appear to be schedule-induced in the usual sense. Rather, the hamsters left the area of the feeder when food was not due and engaged in activities they would normally perform in the experimental environment.

Bone ingrowth into porous silicon nitride

Achieving solid skeletal attachment is a requirement for the clinical success of orthopedic implants. Porous or roughened surfaces and coatings have been developed and used with mixed success to achieve attachment due to bone ingrowth. Silicon nitride is a high performance ceramic whose strength, imaging properties, and biocompatibility make it a candidate material for orthopedic implants. A porous form of silicon nitride, cancellous-structured ceramic (CSC), has been developed. CSC is a nonresorbable, partially radiolucent porous structure that can be bonded to orthopedic implants made of silicon nitride to facilitate skeletal attachment. The purpose of this study was to quantify the extent and rate of bone ingrowth into CSC in a large animal model. Cylindrical implants were placed bilaterally using staged surgeries in the medial femoral condyle of six sheep. Condyles were retrieved after 3 and 6 months in situ and prepared for examination of bone growth under SEM. Bone grew into CSC to extents and at rates similar to those reported for other titanium porous surfaces in studies involving large animals and postmortem retrievals in humans. Bone ingrowth was observed at depths of penetration greater than 3 mm in some implants after only 12 weeks in situ. Bone ingrowth into CSC is a viable method for achieving skeletal attachment.

Risk of autism and increasing maternal and paternal age in a large north American population

Previous studies are inconsistent regarding whether there are independent effects of maternal and paternal age on the risk of autism. Different biologic mechanisms are suggested by maternal and paternal age effects. The study population included all California singletons born in 1989-2002 (n = 7,550,026). Children with autism (n = 23,311) were identified through the California Department of Developmental Services and compared with the remainder of the study population, with parental ages and covariates obtained from birth certificates. Adjusted odds ratios and 95% confidence intervals were used to evaluate the risk of autism associated with increasing maternal and paternal age. In adjusted models that included age of the other parent and demographic covariates, a 10-year increase in maternal age was associated with a 38% increase in the odds ratio for autism (odds ratio = 1.38, 95% confidence interval: 1.32, 1.44), and a 10-year increase in paternal age was associated with a 22% increase (odds ratio = 1.22, 95% confidence interval: 1.18, 1.26). Maternal and paternal age effects were seen in subgroups defined by race/ethnicity and other covariates and were of greater magnitude among first-born compared with later-born children. Further studies are needed to help clarify the biologic mechanisms involved in the independent association of autism risk with increasing maternal and paternal age.

A measure of food seeking in individuals with Prader-Willi syndrome

BACKGROUND

Individuals with Prader-Willi syndrome (PWS), a chromosome 15 genetic disorder, often have a significant preoccupation with food and problem behaviour related to food seeking is often prevalent.

METHODS

In the present study, we compared how individuals with PWS responded on a survey regarding the acceptability of food in various locations that varied according to degree of appropriateness for human consumption (e.g. food on a plate, food in a garbage can). For a subgroup of participants, we observed how they actually responded when placed in a room with food items placed in the same locations depicted in the survey. In the first part of the study, three groups (25 typically developing individuals, 7 individuals with intellectual disability (ID), and 19 individuals with PWS) responded to a visual survey to determine the degree of acceptability of food items in various locations (e.g. on a table near a hairbrush, on the floor behind a toy box, in a trash can). In the second part of the study, these food items (popcorn, jelly beans) were placed in the 12 locations described above. Nine individuals diagnosed with PWS (deletion type) and three individuals with ID were given some break time in the room for 15 min. The amount of food consumed, the time spent food seeking, and time spent interacting with materials were measured.

RESULTS

Results of the survey indicated that the PWS group differed significantly with regard to how they responded on the survey from the typically developing group, but did not differ significantly from the ID group. Results of the food seeking observations indicated that only three individuals with PWS ate a significant number of items. The three individuals did not differ from the rest of the group according to IQ or compulsivity score; however, they had significantly lower body mass index (BMI) scores and were younger than the other participants.

CONCLUSIONS

The findings from the survey indicate that individuals with PWS are able to discriminate the appropriateness of eating items in more or less contaminated areas; however, the amount of time spent seeking food and the amount of food covertly consumed appeared to depend more directly on age and BMI.

Forgetting our facts: the role of inhibitory processes in the loss of propositional knowledge

Seven experiments are reported that show that retrieving facts from long-term memory is accomplished, in part, by inhibitory processes that suppress interfering facts. When asked to repeatedly retrieve a recently learned proposition (e.g., recalling The actor is looking at the tulip, given cues such as Actor looking t__), subjects experienced a recall deficit for related facts (e.g., The actor is looking at the violin) on a recall test administered 15 min later. Importantly, this retrieval-induced forgetting was shown to generalize to other facts in which the inhibited concepts took part (e.g., The teacher is lifting the violin), replicating a finding observed by M. C. Anderson and B. A. Spellman (1995) with categorical stimuli. These findings suggest a critical role for suppression in models of propositional retrieval and implicate the mere retrieval of what we know as a source of forgetting of factual knowledge.

Location of death in Canada. A comparison of 20th-century hospital and nonhospital locations of death and corresponding population trends

This report compares 20th-century Canadian hospital and nonhospital location-of-death trends and corresponding population mortality trends. One of the chief findings is a hospitalization-of-death trend, with deaths in hospital peaking in 1994 at 80.5% of all deaths. The rise in hospitalization was more pronounced in the years prior to the development of a national health care program (1966). Another key finding is a gradual reduction since 1994 in hospital deaths, with this reduction occurring across all sociodemographic variables. This suggests nonhospital care options are needed to support what may be an ongoing shift away from hospitalized death and dying.

Forgetting our facts: the role of inhibitory processes in the loss of propositional knowledge

Seven experiments are reported that show that retrieving facts from long-term memory is accomplished, in part, by inhibitory processes that suppress interfering facts. When asked to repeatedly retrieve a recently learned proposition (e.g., recalling The actor is looking at the tulip, given cues such as Actor looking t__), subjects experienced a recall deficit for related facts (e.g., The actor is looking at the violin) on a recall test administered 15 min later. Importantly, this retrieval-induced forgetting was shown to generalize to other facts in which the inhibited concepts took part (e.g., The teacher is lifting the violin), replicating a finding observed by M. C. Anderson and B. A. Spellman (1995) with categorical stimuli. These findings suggest a critical role for suppression in models of propositional retrieval and implicate the mere retrieval of what we know as a source of forgetting of factual knowledge.

Canopy Wetness and Humidity Prediction Using Satellite and Synoptic-Scale Meteorological Observations

A method for predicting canopy wetness and humidity from remotely-acquired meteorological and radiation data is described. This method employs a surface energy balance model to scale from the above-canopy macroclimate to in-canopy microclimate conditions. Above-canopy temperature, vapor pressure, and wind speed inputs were obtained from objective analyses of hourly measurements from the synoptic weather network, while downwelling long- and shortwave radiation forcings were estimated from standard satellite observations. Precipitation (irrigation + rainfall) was the only input acquired in-field. Model predictions compared well with measurements of nighttime dew accumulation and relative humidity made in irrigated potato crops grown in central Wisconsin. Maximum dew amount measured in full canopies over four nights was reproduced to within 0.05 to 0.1 mm. The practical utility of this method to disease management was assessed by processing modeled and measured canopy microclimate data from two weather stations over three growing seasons through the BLITECAST disease forecasting system. Given the uncertainties inherent in the measurement of humidity, the model reasonably reproduced disease severity values generated from in-situ measurements in all but one case, where the canopy had suffered partial defoliation. Because the model simulates the microclimate within a healthy, uniform canopy, it may in many cases produce more reliable regional forecasts for plant disease than would a single set of in-situ measurements.

Continuing care nurses' perceptions of need for physical assessment skills

The purpose of this descriptive research was to identify the perceived learning needs of registered nurse case managers for physical assessment skills, their facility with computers, and barriers and supports to the enhancement and application of physical assessment by these caregivers in the work-place. Nineteen continuing care facilities in one Alberta Health Region participated. Using data source triangulation, two independent groups, case managers (n = 150) and nurse administrators or staff development officers (n = 39) responded to a questionnaire developed by the researchers. The case managers reported that skill in physical assessment was very important in their work, but current skill was inadequate to meet resident care needs. Both groups ranked the thorax and lungs, cardiovascular/peripheral vascular systems, and abdomen as the top three body systems or regions in terms of the case managers' learning needs. This research identified that for these case managers, upgrading skills in physical assessment was a continuing education priority and suggested computer-assisted instruction as a potential delivery method.

A functional magnetic resonance imaging study of auditory mismatch in schizophrenia

OBJECTIVE

Previous research has noted functional and structural temporal lobe abnormalities in schizophrenia that relate to symptoms such as auditory hallucinations and thought disorder. The goal of the study was to determine whether the functional abnormalities are present in schizophrenia at early stages of auditory processing.

METHOD

Functional magnetic resonance imaging activity was examined during the presentation of the mismatch stimuli, which are deviant tones embedded in a series of standard tones. The mismatch stimuli are used to elicit the mismatch negativity, an early auditory event-related potential. Ten patients with schizophrenia and 10 comparison subjects were presented the mismatch stimuli condition and a control condition in which only one tone was presented repeatedly.

RESULTS

The superior temporal gyrus showed the most prevalent and consistent activation. The superior temporal gyrus showed less activation in the schizophrenic subjects than in the comparison subjects only during the mismatch stimuli condition.

CONCLUSIONS

This result is consistent with those of mismatch negativity event-related potential studies and suggests that early auditory processing is abnormal in chronic schizophrenia.

Suppressing unwanted memories by executive control

Freud proposed that unwanted memories can be forgotten by pushing them into the unconscious, a process called repression. The existence of repression has remained controversial for more than a century, in part because of its strong coupling with trauma, and the ethical and practical difficulties of studying such processes in controlled experiments. However, behavioural and neurobiological research on memory and attention shows that people have executive control processes directed at minimizing perceptual distraction, overcoming interference during short and long-term memory tasks and stopping strong habitual responses to stimuli. Here we show that these mechanisms can be recruited to prevent unwanted declarative memories from entering awareness, and that this cognitive act has enduring consequences for the rejected memories. When people encounter cues that remind them of an unwanted memory and they consistently try to prevent awareness of it, the later recall of the rejected memory becomes more difficult. The forgetting increases with the number of times the memory is avoided, resists incentives for accurate recall and is caused by processes that suppress the memory itself. These results show that executive control processes not uniquely tied to trauma may provide a viable model for repression.

The created environment for physical assessment by case managers

Goals of gerontological nursing include maximizing health and confronting functional impairments. The health of older adults is often fragile because of age-related change, complicated by chronic illnesses. Identification of changes in health status permits responsive care and consultation but requires proficiency in physical assessment. In 1995, research was conducted in Alberta, Canada, on registered nurse case managers' reported use of assessment skills. Nineteen continuing-care facilities in 1 of 17 provincial health regions participated (N = 189). After expert review and pilot testing, questionnaires were distributed to two independent groups: nurse administrators/staff development coordinators and case managers (response rate = 73%). Qualitative data were subjected to descriptive, interpretive, and pattern coding. Reported are factors constraining or facilitating physical assessment in continuing care. Neuman's concept of the created environment provided a factor-organizing framework. A holistic view of environment and data source triangulation increased confidence in the comprehensiveness and credibility of results.

The endometrial response to sequential and continuous combined oestrogen-progestogen replacement therapy

OBJECTIVES

1. To determine the prevalence of endometrial hyperplasia in postmenopausal women taking standard proprietary regimens of sequential oestrogen/progestogen; 2. to determine the effects of nine months treatment with an oral continuous combined regimen of 2 mg 17beta-oestradiol and 1 mg norethisterone acetate (Kliofem [Kliogest outside the UK]; Novo Nordisk, Denmark) on endometrial histology in postmenopausal women.

DESIGN

An open, prospective study in postmenopausal women.

SETTING

Fifty-four menopause clinics in the UK.

PARTICIPANTS

2028 postmenopausal women: 1312 (Group A) taking sequential oestrogen-progestogen hormone replacement therapy (HRT), and 716 (Group B) not taking HRT, were recruited. In Group A, 388 women took preparations containing 10 days of progestogen, 921 had 12 days, and 3 had 13 days per cycle.

METHODS

Endometrial aspiration biopsies were taken towards the end of a three-month run-in period (Group A) or at study entry (Group B), before administration of the continuous combined HRT regimen. Biopsies were repeated at the end of the nine month treatment period.

MAIN OUTCOME MEASURE

Endometrial histology.

RESULTS

Initial endometrial biopsy data were available for 1106 women in Group A, who by the time of endometrial investigation had been taking HRT for a median duration of 2.56 years (5th to 95th centiles: 0.77 to 8.49 years). Data were available for 661 untreated women, who had no bleeding and had not taken HRT within the last year (Group B). Complex hyperplasia was found in 59 women (5.3%), and atypical hyperplasia in a further eight (0.7%) in Group A. In Group B there were no cases with complex hyperplasia, but one woman showed atypical hyperplasia (0.2%). At the end of the nine months of continuous combined therapy there was no case of hyperplasia among 1196 biopsies (upper 95% confidence limit of risk 0.31%) in women completing the study. Within this Group all of the women with complex hyperplasia arising during previous sequential HRT and who completed the study (n = 38) reverted to normal endometrial patterns. There was no case of endometrial carcinoma during the study.

CONCLUSIONS

Despite taking standard regimens of sequential HRT containing at least 10 days of progestogen, there was a 5.3% prevalence of complex endometrial hyperplasia, and a 0.7% prevalence of atypical hyperplasia. However, continuous combined HRT (Kliofem) containing daily progestogen is not associated with an increased risk of hyperplasia and will convert the endometrium to normal in those with complex hyperplasia arising during previous sequential HRT.

Pathology and pathophysiology of uterine smooth-muscle tumors

Smooth-muscle tumors of uterine origin encompass a broad family of neoplasms. The leiomyoma, by far the most common of all the neoplasms, generally is hormone sensitive, with rates of growth semiquantitatively related to estrogen and progesterone receptor levels. Several forms of degenerative change can occur in the leiomyoma. The most common is hyaline degeneration, which is important in that it should not be mistaken for the coagulative tumor cell necrosis seen in leiomyosarcoma. Red degeneration (necrobiosis) is a form of degeneration that occurs characteristically but not exclusively in pregnancy, and the process is often the cause of pain and fever. Several forms of treatment have been used medically in the treatment of leiomyoma. Gonadotropin-releasing hormone analogs or agonists or selective arterial embolization with polyvinylformaldehyde particles may lead to substantial degeneration or infarction of the leiomyoma, respectively. Several variants of leiomyoma, the cellular and symplastic leiomyomas, are important to recognize, as they can be misinterpreted as sarcoma. In addition, there are two unusual growth patterns of leiomyoma that are important to recognize. Both the benign metastasizing leiomyoma and disseminated peritoneal leiomyomatosis are found outside the uterus, and neither is malignant. Recent studies offer insights into their origin and hormonal influences. From a diagnostic and therapeutic point of view, the leiomyosarcoma, while rare, is clinically of great import. Coagulative necrosis, cytologic atypia, and mitotic counts are all important in diagnosing the condition.

Similarity and inhibition in long-term memory: evidence for a two-factor theory

Recalling a past experience often requires the suppression of related memories that compete with the retrieval target, causing memory impairment known as retrieval-induced forgetting. Two experiments examined how retrieval-induced forgetting varies with the similarity of the competitor and the target item (target-competitor similarity) and with the similarity between the competitors themselves (competitor-competitor similarity). According to the pattern-suppression model (M. C. Anderson & B. A. Spellman, 1995), high target-competitor similarity should reduce impairment, whereas high competitor-competitor similarity should increase it. Both predictions were supported: Encoding target-competitor similarities not only eliminated retrieval-induced forgetting but also reversed it, whereas encoding competitor-competitor similarities increased impairment. The differing effects of target-competitor and competitor-competitor similarity may resolve conflicting results concerning the effects of similarity on inhibition.

Retrieval-induced forgetting: evidence for a recall-specific mechanism

Previous work has shown that recalling information from long-term memory can impair the long-term retention of related representations--a phenomenon known as retrieval-induced forgetting (Anderson, Bjork, & Bjork, 1994). We report an experiment in which the question of whether retrieval is necessary to induce this form of impairment was examined. All the subjects studied six members from each of eight taxonomic categories (e.g., fruit orange). In the competitive practice condition, the subjects practiced recalling three of the six members, using category-stem cues (e.g., fruit or__). In the noncompetitive practice condition, the subjects were reexposed to these same members for the same number of repetitions but were asked to recall the category name by using the exemplar and a stem as cues (e.g., fr__orange). Despite significant and comparable facilitation of practiced items in both conditions, only the competitive practice subjects were impaired in their ability to recall the nonpracticed members on a delayed cued-recall test. These findings argue that retrieval-induced forgetting is not caused by increased competition arising from the strengthening of practiced items, but by inhibitory processes specific to the situation of recall.

Organicity in obsessive-compulsive disorder

Though pharmacological and/or behavioral interventions have proven highly effective, 20 to 30% of the obsessive-compulsive disorder (OCD) population is treatment refractory. This study describes the OCD clinical profile that is correlated to organicity. Two groups of OCD patients were presented: an organic group and a control nonorganic group. The 9 organic patients exhibit an indifference to their illness, a lack of motivation, are nonanxious even during exposure exercises, are nondepressed, have rigid and concrete thinking, are treatment refractory, and have some type of organic impairment. The 10 nonorganic patients are also treatment refractory but do not exhibit the clinical profile correlated to the organic OCD patients. Furthermore, MRI results indicate that no organic impairment exists in this control group. All of these patients were tried on medication and behavior therapy to no avail. Reasons for lack of response in organic OCD patients, based on cerebral anatomical changes, are discussed.

White matter abnormalities in mobility-impaired older persons

OBJECTIVE

To investigate the relationship between white matter abnormalities and impairment of gait and balance in older persons.

METHODS

Quantitative MRI was used to evaluate the brain tissue compartments of 28 older individuals separated into normal and impaired groups on the basis of mobility performance testing using the Short Physical Performance Battery. In addition, individuals were tested on six indices of gait and balance. For imaging data, segmentation of intracranial volume into four tissue classes was performed using template-driven segmentation, in which signal-intensity-based statistical tissue classification is refined using a digital brain atlas as anatomic template.

RESULTS

Both decreased white matter volume, which was age-related, and increased white matter signal abnormalities, which were not age-related, were observed in the mobility-impaired group compared with the control subjects. The average volume of white matter signal abnormalities for impaired individuals was nearly double that of control subjects.

CONCLUSIONS

This cross-sectional study suggests that decreased white matter volume is age-related, whereas increased white matter signal abnormalities are most likely to occur as a result of disease. Both of these changes are independently associated with impaired mobility in older persons and therefore likely to be additive factors of motor disability.

Quantitative follow-up of patients with multiple sclerosis using MRI: reproducibility

The reproducibility of an automated method for estimating the volume of white matter abnormalities on brain magnetic resonance (MR) images of multiple sclerosis (MS) patients was evaluated. Twenty MS patients underwent MR imaging twice within 30 minutes. Measurement variability is introduced mainly by MRI acquisition and image registration procedures, which demonstrate significantly worse reproducibility than the image segmentation. The correction of partial volume artifacts is essential for sensitive measurements of overall lesion burden. The average lesion volume difference (bias) between two MR exams of the same MS patient (N = 20) was 0.05 cm3, with a 95% confidence interval between -0.17 and +0.28 cm3, suggesting that the proposed measurement system is suitable for clinical follow-up trials, even in relatively small patient cohorts. The limits of agreement for lesion volume were between -1.3 and +1.5 cm3, implying that in individual patients changes in lesion load need to be at least this large to be detected reliably. This automated method for estimating lesion burden is a reliable tool for the evaluation of MS progression and exacerbation in patient cohorts and potentially also in individual patients.

A genome-wide search for chromosomal loci linked to mental health wellness in relatives at high risk for bipolar affective disorder among the Old Order Amish

Bipolar affective disorder (BPAD; manic-depressive illness) is characterized by episodes of mania and/or hypomania interspersed with periods of depression. Compelling evidence supports a significant genetic component in the susceptibility to develop BPAD. To date, however, linkage studies have attempted only to identify chromosomal loci that cause or increase the risk of developing BPAD. To determine whether there could be protective alleles that prevent or reduce the risk of developing BPAD, similar to what is observed in other genetic disorders, we used mental health wellness (absence of any psychiatric disorder) as the phenotype in our genome-wide linkage scan of several large multigeneration Old Order Amish pedigrees exhibiting an extremely high incidence of BPAD. We have found strong evidence for a locus on chromosome 4p at D4S2949 (maximum GENEHUNTER-PLUS nonparametric linkage score = 4.05, P = 5. 22 x 10(-4); SIBPAL Pempirical value <3 x 10(-5)) and suggestive evidence for a locus on chromosome 4q at D4S397 (maximum GENEHUNTER-PLUS nonparametric linkage score = 3.29, P = 2.57 x 10(-3); SIBPAL Pempirical value <1 x 10(-3)) that are linked to mental health wellness. These findings are consistent with the hypothesis that certain alleles could prevent or modify the clinical manifestations of BPAD and perhaps other related affective disorders.

The core metal-recognition domain of MerR

MerR, the metalloregulatory protein of the mercury-resistance operon (mer) has unusually high affinity and specificity for ionic mercury, Hg(II). Prior genetic and biochemical evidence suggested that the protein has a structure consisting of an N-terminal DNA binding domain, a C-terminal Hg(II)-binding domain, and an intervening region involved with communication between these two domains. We have characterized a series of MerR deletion mutants and found that as little as 30% of the protein (residues 80-128) forms a stable dimer and retains high affinity for Hg(II). Biophysical measures indicate that this minimal Hg(II)-binding domain assumes the structural characteristics of the wild-type full-length protein both in the Hg(II) center itself and in an immediately adjacent helical protein domain. Our observations are consistent with the core Hg(II)-binding domain of the MerR dimer being constituted by a pair of antiparallel helices (possibly in a coiled-coil conformation) comprised of residues cysteine 82 through cysteine 117 from each monomer followed by a flexible loop through residue cysteine 126. These antiparallel helices would have a potential Hg(II)-binding site at each end. However, just as in the full-length protein, only one of these potential binding sites in the deleted proteins actually binds Hg(II).

The endometrial deficient secretory phase

The deficient secretory phase is a functional abnormality of the endometrium that has hitherto been poorly recognized. Endometrial curettings form 34 cases were examined in detail by histology. We also performed morphometric analyses of epithelial cell nuclei and assessed the oestrogen and progesterone receptor status of these cases compared with controls. Clinicopathological correlations were examined. The cases showing the deficient secretory phase were characterized histologically by the presence of elongated, hyperchromatic glandular cell nuclei, diminished or no secretory activity in the second half of the menstrual cycle and poorly developed stroma. Morphometry confirmed that the nuclei were different in shape from those seen at any time during the normal menstrual cycle and from basal endometrium. Nuclear expression of oestrogen and progesterone receptors in formalin-fixed and paraffin-embedded sections was reduced. It is apparent from this study that the endometrial appearances described represent a definable condition that may be linked to menstrual irregularities and, in some circumstances, infertility; it should be more widely recognized.

Glandular lesions of the cervix-cytological and histological correlation

In this retrospective review we assessed the frequency with which atypical glandular cells in cervical smears predict cervical glandular lesions. Asymptomatic patients (n=34) with one or more smears showing atypical glandular cells aand subsequent histopathological assessment were studied. Independent cytological and histological review was undertaken. Cytological review confirmed atypical glandular cells in 29 cases, 17 of which had coexisting squamous dyskaryosis. Histological review of these 29 cases revealed glandular neoplasia in 13 (45%) and microglandular hyperplasia (MEH) in an additional four (14%). Initial reporting had underestimated the prevalence of glandular neoplasia.

Glandular lesions of the cervix: diagnostic and therapeutic dilemmas

The term 'glandular lesions' applies mainly to the spectrum of intraepithelial neoplasia affecting the glandular epithelium of the cervix, but consideration must also be given to non-neoplastic disorders. Various systems of terminology are used, the most satisfactory being low grade and high grade CIGN. The criteria for histological diagnosis are quite well defined, although the distinctions between low grade and high grade lesions and between intraepithelial and early invasive disease can be problematic. Although many cases are initially diagnosed on smears, the cytological diagnosis can also be difficult, particularly when squamous lesions are also present, as happens in about 50% of cases. Both histologically and cytologically, the differential diagnosis between CIGN and non-neoplastic changes must be made. Treatment for high grade lesions has traditionally been hysterectomy, but there is evidence that conization with careful cytological follow-up may be safe in certain circumstances. Women with low grade lesions are generally managed in the same way; the role of cytological surveillance of women with mild glandular abnormalities in their smear is not clear. Although there is evidence to substantiate the belief that CIGN is a precursor of adenocarcinoma of the cervix, very little is known of the natural history of these lesions, their relations to one another and the significance of the low grade abnormalities. This uncertainty hampers a rational approach to management.

On the status of inhibitory mechanisms in cognition: memory retrieval as a model case

Theories of cognition frequently assume the existence of inhibitory mechanisms that deactivate mental representations. Justifying this assumption is difficult because cognitive effects thought to reflect inhibition can often be explained without recourse to inhibitory processes. This article addresses the uncertain status of cognitive inhibitory mechanisms, focusing on their function in memory retrieval. On the basis of a novel form of forgetting reported herein, it is shown that classical associative theories of interference are insufficient as accounts of forgetting and that inhibitory processes must be at work. It is argued that inhibitory processes are used to resolve computational problems of selection common to memory retrieval and selective attention and that retrieval is best regarded as conceptually focused selective attention.

Remembering can cause forgetting: retrieval dynamics in long-term memory

Three studies show that the retrieval process itself causes long-lasting forgetting. Ss studied 8 categories (e.g., Fruit). Half the members of half the categories were then repeatedly practiced through retrieval tests (e.g., Fruit Or_____). Category-cued recall of unpracticed members of practiced categories was impaired on a delayed test. Experiments 2 and 3 identified 2 significant features of this retrieval-induced forgetting: The impairment remains when output interference is controlled, suggesting a retrieval-based suppression that endures for 20 min or more, and the impairment appears restricted to high-frequency members. Low-frequency members show little impairment, even in the presence of strong, practiced competitors that might be expected to block access to those items. These findings suggest a critical role for suppression in models of retrieval inhibition and implicate the retrieval process itself in everyday forgetting.

Remembering can cause forgetting: retrieval dynamics in long-term memory

Three studies show that the retrieval process itself causes long-lasting forgetting. Ss studied 8 categories (e.g., Fruit). Half the members of half the categories were then repeatedly practiced through retrieval tests (e.g., Fruit Or_____). Category-cued recall of unpracticed members of practiced categories was impaired on a delayed test. Experiments 2 and 3 identified 2 significant features of this retrieval-induced forgetting: The impairment remains when output interference is controlled, suggesting a retrieval-based suppression that endures for 20 min or more, and the impairment appears restricted to high-frequency members. Low-frequency members show little impairment, even in the presence of strong, practiced competitors that might be expected to block access to those items. These findings suggest a critical role for suppression in models of retrieval inhibition and implicate the retrieval process itself in everyday forgetting.

Outcome after lateral pancreaticojejunostomy for chronic pancreatitis

OBJECTIVE

To assess the outcome of lateral pancreaticojejunostomy in patients with chronic pancreatitis.

SUMMARY BACKGROUND DATA

Chronic fibrocalcific pancreatitis associated with pancreatic ductal dilation and chronic pain has been managed successfully with lateral pancreaticojejunostomy. Early results, measured by pain relief and postoperative morbidity and mortality, have been excellent; however, long-term follow-up and overall outcome has been less clearly defined in these patients.

METHODS

The outcome of 85 patients who had lateral pancreaticojejunostomy was assessed by reviewing hospital inpatient and outpatient records and conducting patient telephone interviews.

RESULTS

Of 62 patients who were alive at follow-up, health status was characterized as good in 24%, fair in 31%, and poor in 45%. Alcohol abuse continued in 42% of patients, whereas narcotic use continued in 35%, insulin use continued in 23%, and pancreatic enzyme supplementation continued in 34%. Rehospitalization for recurrent attacks of pancreatitis and pain was necessary in 40% of patients. Six patients required subsequent operations for complications of chronic pancreatitis. Death occurred in 22 patients (26%) and resulted from continued alcohol abuse, progression of chronic pancreatitis, or late complications of the operation in more than one half the cases.

CONCLUSIONS

Although lateral pancreaticojejunostomy provided pain relief, had a low morbidity rate, and no early postoperative deaths, long-term outcome was poor based on the patient's health status, continued alcohol and narcotic use, employment status, subsequent hospitalization to treat recurrent pancreatitis or its complications, subsequent operations required for complications of chronic pancreatitis, and postoperative deaths related to comorbid medical conditions or complications of chronic pancreatitis.

Estimation of monoamine oxidase concentrations in soluble and membrane-bound preparations by inhibitor binding

A modification of the [3H]-pargyline labelling technique is presented for determining the active-site concentration of monoamine oxidase in soluble preparations. Kinetic considerations show that the rate of reaction of MAO-A with low concentrations of free pargyline will be very much slower than that of MAO-B. Failure to use adequate reaction times for the concentration of pargyline added can lead to gross underestimation of the quantity of MAO-A present.

Colonic complications of pancreatitis

A retrospective review of 296 patients referred for surgical management of pancreatitis from 1964 to 1992 revealed that 18 (6.1%) had colonic complications. Of seven patients with chronic pancreatitis, six developed pancreatocolonic fistulas. One had stenosis of the transverse colon, which resolved after pancreatic cystjejunostomy, three were managed with local fistula excision and simple colon closure, three had segmental colectomy, and in one the fistula closed spontaneously with expectant management. Three patients had concomitant lateral pancreaticojejunostomy, and two had a cystjejunostomy. There were two postoperative complications, but no mortality. Eleven patients had acute necrotizing pancreatitis. Seven developed segmental colonic infarction that required partial colectomy. Four had colonic fistulas, two managed with partial colectomy and colostomy, and two managed nonoperatively. Eleven patients developed major postoperative complications; four died, two from sepsis and multiorgan failure and two from recurrent hemorrhage from a necrotic pancreatic bed. Our findings indicate that the presentation, management, and outcome of colonic complications differ in chronic and acute pancreatitis. In chronic pancreatitis, pancreatocolonic fistula predominated and could be managed either with local excision or segmental resection of the colon with excellent results. Simultaneous surgical correction of associated pancreatic pathology was possible in five patients. In acute necrotizing pancreatitis, colonic infarction secondary to the necrotizing inflammatory process was frequent and required colon resection. There was substantial morbidity and mortality in spite of treatment with colectomy.

Monoamine oxidase inhibitors and the cheese effect

The behavior of inhibitors of monoamine oxidase-A (MAO-A) is considered in terms of the possibility of having an effective antidepressant that does not give rise to hypertensive interactions with dietary tyramine. Studies with punch-biopsy samples of human intestine and rat intestinal samples show MAO-A to be the predominant form of the enzyme in both species. Transport studies with everted rat intestinal preparations indicate that tyramine is extensively metabolized during transport through the intestine. Selective inhibition of MAO-A by clorgyline results in a large increase in the amount of unchanged tyramine transported, whereas selective inhibition of MAO-B with L-deprenyl (selegiline) has no significant effect. The behavior of reversible MAO-A inhibitors can significantly reduce, but not entirely eliminate, these effects on the intestinal metabolism of tyramine, but only if the inhibition is competitive in nature.

Invasive carcinoma of the cervix following local destructive treatment for cervical intraepithelial neoplasia

OBJECTIVE

To investigate the occurrence of invasive carcinomas following local destructive treatment for cervical intraepithelial neoplasia (CIN) and to evaluate the factors responsible.

DESIGN

A multicentre retrospective study.

SUBJECTS

Forty-nine women registered with the British Society for Colposcopy and Cervical Pathology from 24 centres throughout Great Britain between 1985 and 1992, who had been treated by local destructive methods for CIN and who subsequently developed invasive carcinoma of the cervix.

RESULTS

Of the 49 women whose details were submitted, 42 had squamous cell carcinoma, six adenosquamous carcinoma and one adenocarcinoma. Eight had microinvasive carcinomas (Stage Ia) at the time of diagnosis, 24 had Stage Ib tumours and eight Stages II to IV. Thirteen women have died. Thirty-five women had been treated by laser vaporization, ten by cold coagulator, two by diathermy and two by cryosurgery. In 19 women (39%) the diagnosis of invasive carcinoma was made on the first follow up visit or within one year of treatment. Five patients did not present with invasive disease until more than five years after treatment.

CONCLUSIONS

The data presented suggest that many, but not all, of the invasive carcinomas presenting after local destructive treatment for CIN resulted from failure to recognise early invasive disease at the time of the initial assessment. The importance of thorough evaluation before undertaking these forms of treatment is emphasised. The use of excisional procedures should further reduce the small risk of invasive carcinoma developing after treatment for CIN.

The Royal College of Obstetricians and Gynaecologists micro-invasive carcinoma of the cervix study: preliminary results

OBJECTIVES

To determine how micro-invasive carcinoma of the cervix is diagnosed and treated in the United Kingdom. To record the frequency of the various pathological features which comprise the histological diagnosis of micro-invasion, and to assess their relevance to outcome.

DESIGN

Prospective observational study.

SETTING

Hospitals throughout the United Kingdom.

SUBJECTS

Two hundred and eighty-six cases were submitted for entry into the study. Following independent review of the histological material 116 cases were excluded: 41 were not accompanied by histological slides for review, 55 had no evidence of invasive disease, 17 had invasive disease greater than FIGO Stage 1a, and three were adenocarcinomas. The remaining 170 cases were registered for the study but follow up was incomplete in 18. This report concerns the 152 women with complete follow up to 1991.

RESULTS

The age of the 152 women ranged from 22 to 65 years (median 36 years). In 116 women (76%) the diagnosis was made by cone biopsy (cold knife, loop diathermy, or laser) or wedge biopsy, in 9 women (6%) the diagnosis was made by hysterectomy, and in 27 women (18%) punch biopsy suggested an invasive lesion and subsequent excisional treatment (including radical hysterectomy with node dissection in three) demonstrated micro-invasion. The depth of invasion was up to 3 mm in 142 women (93%) and 3.1 to 5 mm in 10 women (7%). Capillary-like space involvement was present in 12 women (8%). Treatment methods used were local cervical surgery in 79 women (52%), simple hysterectomy in 63 (41%), and radical hysterectomy in 10 (7%). There was only one known recurrence and death due to cervical carcinoma.

CONCLUSION

There is no uniformity in the management of micro-invasive carcinoma of the cervix. The frequency of recurrence, lymph metastases, and death is low. Nonradical surgery appears to give satisfactory results.

Arterial hemorrhage complicating pancreatic pseudocysts: role of angiography

Major arterial hemorrhage associated with pancreatic pseudocysts represents a formidable complication with high mortality rates. This study was undertaken to analyze presentation and outcome and to assess the role of angiography in diagnosis and management of this complication. A retrospective review of 180 patients referred for surgical management of pancreatic pseudocysts from 1964 to 1991 identified 13 patients (7.2%) with arterial hemorrhage. Eight patients presented with intracystic hemorrhage, 4 with upper gastrointestinal bleeding, and 1 with intra-abdominal bleeding. Six patients had gastroduodenal artery bleeding, 4 splenic, and 1 each left gastric, right colic, and left gastroepiploic. The site of bleeding was identified with selective visceral angiography in 9 patients; evidence of pseudocyst bleeding was seen in 5 of 7 patients who had contrast-enhanced computerized tomography (CT) scans. Angiographic embolization for control of hemorrhage was used in 6 patients and operative control in 7. Over the past decade, bleeding has been controlled with angiographic embolization in all patients except 1 with massive bleeding due to splenic artery erosion. Average blood loss was less in patients treated with angiographic embolization (6.8 vs 17.5 units, packed red cells, P < .05, Wilcoxon rank sum test). The sole mortality was a patient with cirrhosis treated in 1969. Clinical presentation of pseudocyst bleeding is variable; the underlying cause is usually related to chronic pancreatitis due to alcohol abuse. The dynamic contrast-enhanced CT scan is valuable in demonstrating evidence of pseudocyst bleeding. Accurate diagnosis with dynamic CT scan and angiography and control of bleeding with angiographic embolization has improved the outcome in patients with this complication.

Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst

The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p less than 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p less than 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.