Restarted replication forks are error-prone and cause CAG repeat expansions and contractions

Disease-associated trinucleotide repeats form secondary DNA structures that interfere with replication and repair. Replication has been implicated as a mechanism that can cause repeat expansions and contractions. However, because structure-forming repeats are also replication barriers, it has been unclear whether the instability occurs due to slippage during normal replication progression through the repeat, slippage or misalignment at a replication stall caused by the repeat, or during subsequent replication of the repeat by a restarted fork that has altered properties. In this study, we have specifically addressed the fidelity of a restarted fork as it replicates through a CAG/CTG repeat tract and its effect on repeat instability. To do this, we used a well-characterized site-specific replication fork barrier (RFB) system in fission yeast that creates an inducible and highly efficient stall that is known to restart by recombination-dependent replication (RDR), in combination with long CAG repeat tracts inserted at various distances and orientations with respect to the RFB. We find that replication by the restarted fork exhibits low fidelity through repeat sequences placed 2–7 kb from the RFB, exhibiting elevated levels of Rad52- and Rad8^{ScRad5/HsHLTF}-dependent instability. CAG expansions and contractions are not elevated to the same degree when the tract is just in front or behind the barrier, suggesting that the long-traveling Polδ-Polδ restarted fork, rather than fork reversal or initial D-loop synthesis through the repeat during stalling and restart, is the greatest source of repeat instability. The switch in replication direction that occurs due to replication from a converging fork while the stalled fork is held at the barrier is also a significant contributor to the repeat instability profile. Our results shed light on a long-standing question of how fork stalling and RDR contribute to expansions and contractions of structure-forming trinucleotide repeats, and reveal that tolerance to replication stress by fork restart comes at the cost of increased instability of repetitive sequences.

Trinucleotide repeat expansions are the cause of several muscular- and neuro-degenerative diseases, and further expansions during intergenerational inheritance often leads to an earlier age-of-onset in the offspring. Some intergenerational expansions appear to occur during germ cell replication, but how those replication-associated expansions arise is incompletely understood. Because there are many replication barriers in genomes, including the structure-forming repeats themselves, we investigated whether a repeat placed after such a barrier had altered instability. We discovered that a restarted replication fork traversing a CAG repeat tract is highly error prone and repeat expansions and contractions are more prevalent in this case compared to normal replication. These results reveal a mechanism for replication-associated repeat instability relevant to disease-associated trinucleotide repeat expansions.

A Randomized Controlled Trial to Compare Computer-assisted Motivational Intervention with Didactic Educational Counseling to Reduce Unprotected Sex in Female Adolescents

STUDY OBJECTIVE

To examine a computer-assisted, counselor-guided motivational intervention (CAMI) aimed at reducing the risk of unprotected sexual intercourse. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a 9-month, longitudinal randomized controlled trial with a multisite recruitment strategy including clinic, university, and social referrals, and compared the CAMI with didactic educational counseling in 572 female adolescents with a mean age of 17 years (SD = 2.2 years; range = 13-21 years; 59% African American) who were at risk for pregnancy and sexually transmitted diseases. The primary outcome was the acceptability of the CAMI according to self-reported rating scales. The secondary outcome was the reduction of pregnancy and sexually transmitted disease risk using a 9-month, self-report timeline follow-back calendar of unprotected sex.

RESULTS

The CAMI was rated easy to use. Compared with the didactic educational counseling, there was a significant effect of the intervention which suggested that the CAMI helped reduce unprotected sex among participants who completed the study. However, because of the high attrition rate, the intent to treat analysis did not demonstrate a significant effect of the CAMI on reducing the rate of unprotected sex.

CONCLUSION

Among those who completed the intervention, the CAMI reduced unprotected sex among an at-risk, predominantly minority sample of female adolescents. Modification of the CAMI to address methodological issues that contributed to a high drop-out rate are needed to make the intervention more acceptable and feasible for use among sexually active predominantly minority, at-risk, female adolescents.

A phase II evaluation of motesanib (AMG 706) in the treatment of persistent or recurrent ovarian, fallopian tube and primary peritoneal carcinomas: a Gynecologic Oncology Group study

OBJECTIVES

Vascular endothelial growth factors (VEGF) and their receptors have a critical role in stimulating the growth of ovarian cancer cells. Motesanib is a small molecule inhibitor of multiple receptor tyrosine kinases including VEGF receptors 1-3, as well as c-KIT and platelet-derived growth factor which are related to the VEGF family.

PATIENTS AND METHODS

Twenty-two eligible patients with recurrent ovarian, fallopian tube or primary peritoneal carcinoma were treated with an oral daily dose of 125 mg of motesanib. Peripheral blood was analyzed for circulating tumor cells (CTC) and circulating endothelial cells/circulating endothelial progenitors (CEC/CEP), VEGF levels and cell-free circulating DNA (cfDNA).

RESULTS

The study was abruptly halted after four patients developed posterior reversible encephalopathy syndrome. One patient had a partial response and seven patients had stable disease at the time they were removed from study treatment. Twelve of the 22 patients (50%) had indeterminate responses at trial closure. Early closure without clinical efficacy data precludes meaningful correlative studies.

CONCLUSIONS

The serious central nervous system toxicity observed in patients with recurrent ovarian cancer precluded full examination of this agent in this population. There were no clear cut explanations for the high incidence of this known class effect in the study population compared with patients with other cancers.

Inadequate vitamin D status in adolescents with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate injectable contraceptive: a pilot study

STUDY OBJECTIVE

To examine vitamin D and parathormone (PTH) levels in adolescents who experienced substantial bone mineral density (BMD) loss during depot medroxyprogesterone acetate (DMPA) use.

DESIGN

A non-randomized, multi-center study, during which DMPA was administered every 12 weeks and evaluation of lumbar spine and hip BMD by dual-energy X-ray absorptiometry (DXA) was conducted every 6 months. A blood sample for vitamin D and PTH measurements was obtained from adolescents who experienced >5% BMD loss. Vitamin D deficiency was defined as 25-hydroxyvitamin D (25OHD) level of <20 ng/mL, insufficiency as 25OHD level of 20-30 ng/mL, and sufficiency as 25OHD level of >30 ng/mL.

RESULTS

Evaluation of vitamin D and PTH was carried out in 15 participants who experienced BMD loss of > or = 5% during DMPA use. At initiation of DMPA, participants had mean (+SE) age 17+1 years, gynecologic age 61+4 months, and body mass index 24+1.5 kg/m2. Racial/ethnic distribution was: Caucasian--7 girls, Hispanic--4 girls, African-American--3 girls, and other--1 girl. Six participants had BMD loss of >5% after 2 DMPA injections, five after 3 injections, one after 5 injections, one after 8 injections, one after 10 injections, and one after 13 injections. Only one girl (7%) had sufficient vitamin D. The other participants had vitamin D insufficiency (50%) or deficiency (43%). Participants' mean (+SE) PTH was 22+4 pg/mL (reference range 7-53 pg/mL), and mean (+SE) 1,25-dihydroxyvitamin D was 56+5 pg/mL (reference range 22-67 pg/mL).

CONCLUSIONS

Inadequate vitamin D status was evident among the majority of female adolescents who experienced a substantial BMD loss while using DMPA.

HEMOGLOBIN PRECIPITATION IN RENAL TUBULES : A STUDY OF ITS CAUSES AND EFFECTS

1. A readily reproducible pathological lesion closely resembling that typical of the "transfusion kidney" has been obtained by the injection of hemoglobin into rabbits having acid urine, whose renal tubules had previously been damaged to a moderate degree by (a) a short period of complete renal ischemia, or (b) the administration of a specific chemical poison-sodium tartrate. 2. It has been found that hemoglobin is precipitated in the tubules of damaged kidneys excreting either acid or alkaline urine, in contrast to the absence of hemoglobin precipitation in normal kidneys. 3. In the acid state hemoglobin casts are more numerous and more persistent than in the alkaline, and are associated with renal functional disturbances, in contrast to the lack of such disturbances when the urine is alkaline. 4. The ultimate outcome, both anatomically and functionally, in any given instance is determined by variations in the degree of tubular damage, the level of hemoglobinemia, and the urinary pH.

Associations between depressive symptoms and sexual risk behavior in a diverse sample of female adolescents

STUDY OBJECTIVE

To determine associations between depressive symptoms, locus of control, and sexual outcomes in a predominantly African-American cohort of female adolescents.

DESIGN

A computerized assessment was administered to participants as part of a larger randomized clinical trial. We assessed sexual risk behaviors (SRBs) via self-report, and we assessed depressive symptoms using the Center for Epidemiologic Studies Depression Scale. We used multivariate regression to determine associations between depressive symptoms and outcomes while controlling for covariates.

SETTING

This was a secondary analysis of baseline data collected during a randomized clinical trial intended to prevent unintended pregnancy and sexually transmitted infections (STIs).

PARTICIPANTS

572 adolescent females, ages 13 to 21 years, were recruited via a hospital-based adolescent clinic and community-wide advertisements.

MAIN OUTCOME MEASURES

Participants reported on prior sexual intercourse, number of lifetime partners, frequency of intercourse, history of pregnancies and STIs, and locus of control.

RESULTS

Two thirds of the sample had been sexually active. In a model that controlled for all covariates, those with a high level of depressive symptoms had higher odds of having had intercourse (adjusted OR = 2.29; 95% CI = 1.18-4.43). High levels of depressive symptoms were also independently associated with increased numbers of lifetime sexual partners and an external locus of control. However, when depression and locus of control were included in the same model, locus of control was not independently associated with SRBs.

CONCLUSION

These findings support other literature demonstrating an association between depression and SRBs, particularly in a largely African-American population. They further suggest that perceived control does not fully explain the relationship between depression and SRBs.

Salvage of isolated vaginal recurrences in women with surgical stage I endometrial cancer: a multiinstitutional experience

The objective of this study was to evaluate the treatment outcomes and risk factors of women with surgical stage I endometrial adenocarcinoma who were initially treated with surgery alone and subsequently developed isolated vaginal recurrences. Patients with surgical stage I endometrial adenocarcinoma diagnosed from 1975 to 2002 were identified from tumor registry databases at seven institutions. All patients were treated with surgery alone including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic (+/- para-aortic) lymph node dissection, and peritoneal cytology and did not receive postoperative radiation therapy. Vaginal recurrences were documented histologically. Metastatic disease in the chest and abdomen was excluded by radiologic studies. Overall survival was calculated by the Kaplan-Meier method. Sixty-nine women with surgical stage I endometrial cancer with isolated vaginal recurrences were identified. Of the 69 patients, 10 (15%) were diagnosed with stage IA disease, 43 (62%) were diagnosed with stage IB disease, and 16 (23%) were diagnosed with stage IC disease. Patients diagnosed with grade 1 disease were 22 (32%), grade 2 disease were 26 (38%), and grade 3 disease were 21 (30%). Among women, 81% with isolated vaginal recurrences were salvaged with radiation therapy. The mean time to recurrence was 24 months, and the mean follow-up was 63 months. Among women, 18% died from subsequent recurrent disease. The 5-year overall survival was 75%. The majority of isolated vaginal recurrences in women with surgical stage I endometrial cancer can be successfully salvaged with radiation therapy, further questioning the role of adjuvant therapy for patients with uterine-confined endometrial cancer at the time of initial diagnosis.

Panniculectomy with simultaneous gynecologic oncology surgery

OBJECTIVE

The objective was to report the utility and morbidity of panniculectomy in obese gynecologic oncology patients undergoing exploratory laparotomy.

METHODS

A retrospective chart review of 41 consecutive women who had a panniculectomy as part of an abdominal gynecologic oncology procedure between July 1996 and May 2000 was performed. Obese patients possessing a large pannus, the majority with a BMI > or = 30 kg/m(2), were included. Demographic, preoperative, operative, and postoperative data were obtained. Statistical analyses were performed using Statistical Analysis System (SAS) Version 6.13.

RESULTS

Panniculectomy was performed on 41 patients with a mean age of 55, weight of 126 kg, and BMI of 48 kg/m(2). The most common comorbidities in this population were hypertension, diabetes, and osteoarthritis. Wound infection occurred in 4 (9.8%) patients; 88% of the patients received a hysterectomy. The average EBL was 358 cc. Operative time and length of hospital stay were on average 203 min and 5.5 days, respectively. A prior history of diabetes increased the risk of early complications (P = 0.03). Late complications were more likely to occur in older women (P = 0.05). Wound complications were increased in patients with larger BMI's (P = 0.05).

CONCLUSIONS

This study supports the safety of the panniculectomy procedure in this high-risk group of morbidly obese patients for whom a technical advantage may be achieved by improved operative exposure.

Surgical management of early-stage endometrial cancer in the elderly: is laparoscopy feasible?

OBJECTIVE

To give insight into the utility of laparoscopic staging of endometrial cancer in the elderly population by reviewing the surgical management of clinically stage I endometrial cancer patients.

METHODS

A retrospective analysis evaluating patients that were > or =65 years old and had planned laparoscopic staging, traditional staging via a laparotomy, or a transvaginal hysterectomy as management of their early endometrial cancer. The laparoscopic group had complete staging with bilateral pelvic and paraaortic lymph node dissections and was compared to the group who had staging performed via laparotomy. Patients were identified by our institution's database and data were collected by review of their medical records. Data were collected on demographics, pathology, and procedural information including completion rates, operating room (OR) time, estimated blood loss (EBL), transfusions, lymph node count, complications, and length of stay. Associations between variables were analyzed by Student's t tests and chi(2) testing using Excel v. 9.0.

RESULTS

From February 25, 1994, through December 21, 2000, 125 elderly patients were identified. Sixty-seven patients had planned laparoscopic staging (Group 1), 45 patients had staging via planned laparotomy (Group 2), and 13 patients had a transvaginal hysterectomy (Group 3). Group 1 and Group 2 were compared regarding surgical and postoperative data. Age was not different between these groups (75.9 vs 74.7 years, P = NS). Quetelet index was also similar (29.4 vs 29.9, P = NS) 32.8% of Group 1 had > or =1 previous laparotomy compared to 51.1% in Group 2 (P = NS). In Group 1, 53/67 (79.1%) had stage I or II disease compared to 29/45 (64.4%) in Group 2 (P = NS). Laparoscopy was completed in 52/67 (77.6%) attempted procedures. The reasons for conversion to laparotomy were obesity 7/67 (10.4%), bleeding 4/67 (6.0%), intraperitoneal cancer 3/67 (4.5%), and adhesions 1/67 (1.5%). OR time was significantly longer in successful Group 1 patients compared to Group 2 patients (236 vs 148 min, p = 0.0001). EBL was similar between these groups (298 vs 336 ml, P = NS). Ten of 52 (19.2%) of successful Group 1 patients received a blood transfusion compared to 1/45 (2.2%) of Group 2 patients (P < 0.0001). Pelvic, common iliac, and paraaortic lymph node counts were similar between successful Group 1 patients and those in Group 2 combined with those that received a laparotomy in Group 1 (17.8, 5.2, 6.6 vs 19.1, 5.1, 5.2, P = NS). Length of stay (LOS) was significantly shorter in Group 1 versus Group 2 (3.0 vs 5.8 days, P < 0.0001). There were less fevers (6.0 vs 15.6%, P = 0.01), less postoperative ileus's (0 vs 15.6%, P < 0.001), and less wound complications (6.0 vs 26.7%, P = 0.002) in Group 1 compared to Group 2. Group 3 average age was 77.5 years. Concurrent medical comorbidities were the main reason for the transvaginal approach. OR time averaged 104.5 min. The average length of stay was 2.1 days with no procedural or postoperative complications.

CONCLUSIONS

The favorable results from this retrospective study refute the bias that age is a relative contraindication to laparoscopic surgery. Laparoscopic staging was associated with an increased OR time and an increased rate of transfusion but equivalent blood loss and lymph node counts. Possible advantages are decreased length of stay, less postoperative ileus, and less infections complications. Transvaginal hysterectomy still remains a proven option for women with serious comorbid medical problems with short OR times, minimal complications, and short lengths of stay.

Ovarian cancer metastatic to the brain: what is the optimal management?

PURPOSE

To better define determinants of survival and optimal management strategies for patients with ovarian cancer and brain metastases.

METHODS

A review of literature using Medline identified 15 case series of ovarian cancer patients with brain metastases (OBM). Each article was abstracted for survival data, and in all cases, the intervals between ovarian cancer diagnosis and brain metastasis identification, and between brain metastasis identification and last follow-up were recorded. Cases were categorized by patient characteristics and treatment modality for brain metastases. Estimated survival probabilities were plotted using the Kaplan-Meier method with differences between subgroups analyzed by the log-rank test. Cox proportional hazards model was used to identify independent prognostic factors age, number of metastasis, and treatment modality associated with survival.

RESULTS

The median interval from ovarian cancer diagnosis to brain metastasis in 104 identified patients was 19.5 months. Brain metastasis was single in 43%, multiple in 41%, and not reported in 16% of cases. About 81.7% of patients were treated for their brain metastases using external radiation therapy (XRT), chemotherapy, and surgery. XRT was utilized in 76% of 104 patients and in 93% of treated patients. The most commonly used modalities were XRT alone (40%) and craniotomy and XRT (17%). The median survival (MS) for all patients regardless of treatment type was 6 months. Patients who received any treatment lived longer than those not receiving surgery/chemotherapy/XRT (MS; 7 months vs. 2 months, P = 0.0001). Patients with single brain metastasis had a longer median survival (21 months vs. 6 months, P = 0.049) when treated with craniotomy plus radiation and/or chemotherapy compared to treatment regimens that excluded craniotomy. In a multivariate analysis, only treatment type was significant in predicting survival.

CONCLUSION

OBM portends a poor prognosis, however, long-term survival is possible. Patients appear to benefit from therapy, especially selected groups of OBM patients with single brain metastasis treated with radiation therapy and surgery.

New options in contraception for adolescents

There have been several recent advances in the contraceptive methods available to adolescents in the United States. A new monthly injectable method combines efficacy and ease of compliance with excellent menstrual cycle control. Very low-dose oral contraceptive pills containing gonane progestins decrease the incidence of estrogen-related side effects, and are associated with low rates of breakthrough bleeding. Oral contraceptive pills prescribed in continuous cycles can provide relief from menstrual-related symptoms, and may improve contraceptive effectiveness. Noncontraceptive benefits of oral contraceptive pills, such as improvement in dysmenorrhea and acne, may motivate more consistent pill-taking, and should be identified as additional reasons for pill continuation. Maximizing the prescribing time limit of emergency contraception to 120 hours after unprotected intercourse may improve access. Emergency contraception is more effective the sooner it is used, and should be provided in advance to adolescents for immediate use in the event a postcoital method becomes necessary.

Laparoscopic pelvic and paraaortic lymph node dissection: analysis of the first 100 cases

OBJECTIVE

The aim of this study was to analyze the first 100 cases of planned laparoscopic pelvic and paraaortic lymph node dissection (LND) done for staging of gynecologic cancers. The goal of the study was to assess prognostic factors for conversion to laparotomy and document complications.

METHODS

A retrospective review of patients who had planned laparoscopic bilateral pelvic and bilateral paraaortic LND for staging of their gynecologic cancer was performed. Patients were identified by our institutional database and data were collected by review of their medical records. Data were obtained regarding demographics, stage, histology, length of stay, and procedural information including completion rates, operating room time, estimated blood loss, assistant, lymph node count, and complications. Associations between variables were analyzed using Student t tests, analysis of variance, and chi(2) testing (Excel v7.0).

RESULTS

A total of 103 patients were identified from 12/15/95 to 8/28/00. Demographics included mean age of 66.2 (25-92) and mean Quetelet index (QI) of 30.8 (15.9-56.1). A total of 34/103 (33.0%) had > or =1 previous laparotomy. Ninety-five patients had endometrial cancer and 8 had ovarian cancer. Eighty-six of 103 (83.5%) were stage I or II. The length of stay was shorter for those who had laparoscopy than for those who needed conversion to laparotomy (2.8 vs 5.6 days, P < 0.0001). Laparoscopy was completed in 73/103 (70.9%) of the cases. Completion rates were 62/76 (81.6%) with QI < 35 vs 11/27 (40.7%) with QI > or = 35, P < 0.001. Significantly more patients had their laparoscopy completed when an attending gynecologic oncologist was the first assistant compared to a fellow or a community obstetrician/gynecologist (92.9%, 69.0%, 64.5%, P < 0.0001). The top three reasons for conversion to laparotomy were obesity, 12/30 (29.1%), adhesions, 5/30 (16.7%), and intraperitoneal disease, 5/30 (16.7%). Pelvic, common iliac, and paraaortic lymph node counts did not differ when compared to those of patients who had conversion to laparotomy (18.1, 5.1, 6.8 vs 17.3, 5.7, 6.8, P = ns). Complications included 2 urinary tract injuries, 2 pulmonary embolisms, and 6 wound infections (all in the laparotomy group). Two deaths occurred, 1 due to a vascular injury on initial trocar insertion and 1 due to a pulmonary embolism after a laparotomy for bowel herniation through a trocar incision.

CONCLUSION

Laparoscopic bilateral pelvic and paraaortic LND can be completed successfully in 70.9% of patients. Age, obesity, previous surgery, and the need to perform this procedure in the community were not contraindications. Advantages include a shorter hospital stay, similar nodal counts, and acceptable complications.

A Retrospective Analysis of Radical Hysterectomies Done for Cervical Cancer: Is There a Role for the Pfannenstiel Incision?

OBJECTIVE

The goal of this work was to review patients with early-stage cervical cancer undergoing radical hysterectomy, comparing Pfannenstiel and vertical midline incisions for surgical feasibility, complications, and length of stay.

METHODS

Patients were identified by searching our institutional database. Data were collected from review of each patient's medical record, including demographics, cancer stage, histology, procedural information, length of stay, and complications. Associations between variables were studied using chi(2) and two-tailed t tests. Multivariate analysis was performed using logistic regression.

RESULTS

Between March 1996 and June 2000, 113 patients from the University and Presbyterian Hospitals, Oklahoma City, Oklahoma, underwent radical hysterectomy and pelvic and paraortic lymph node dissection with records available for review. Group 1 consisted of 40 patients who had vertical incisions and group 2 consisted of 73 patients who had Pfannenstiel incisions. There was no difference in race, number of previous abdominal surgeries, distribution of stage, histology, percentage of type III hysterectomies, estimated blood loss, nodal counts, pathologic margin positivity, and postoperative complications among the two groups. Group 2 were younger (41.6 vs 46.5, P = 0.02) and had a lower average QI than group 1 (24.9 vs 28.9, P = 0.001). Group 2 also had a shorter average hospital stay (4.6 days vs 5.8 days, P = 0.04) and shorter operative time (215 min vs 273 min, P = 0.09). Multivariate analysis resulted in Pfannenstiel incisions (P = 0.002), younger age (P = 0.004), and smaller body mass index (P = 0.01) being significant predictors of length of stay.

CONCLUSIONS

Pfannenstiel incisions are feasible without increased morbidity and equal nodal retrieval as compared with vertical midline incisions in patients with early-stage cervical cancer. Pfannenstiel incisions may offer an advantage besides cosmesis in the form of shorter operating room time and earlier discharge from the hospital.

Effects of retinoids on cancerous phenotype and apoptosis in organotypic cultures of ovarian carcinoma

BACKGROUND

Retinoic acid analogues, called retinoids, have shown promise in clinical trials in preventing breast and ovarian cancers. Classic retinoids bind to retinoic acid receptors, which regulate cell growth. Some novel retinoids, such as fenretinide, i.e., N-(4-hydroxyphenyl)retinamide (4-HPR), induce apoptosis through retinoic acid receptor-independent mechanisms; however, they appear to do so only at concentrations above those achieved in clinical chemoprevention trials. At lower concentrations (< or =1 microM), 4-HPR acts like classic retinoids, by inducing differentiation through a receptor-dependent mechanism. Our goal was to compare the effects of novel receptor-independent (apoptotic) retinoids with those of classic growth-inhibitory retinoids at clinically achievable doses on growth, differentiation, and apoptosis in ovarian tissue.

METHODS

Four receptor-independent (apoptotic) and seven growth-inhibitory retinoids, including synthetic, low-toxicity compounds called heteroarotinoids, were administered at concentrations of 1 microM to organotypic cultures of ovarian primary and cancer cell lines: OVCAR-3, Caov-3, and SK-OV-3. After fixation, embedding, and sectioning, the growth fraction was quantified by measuring expression of the proliferation marker Ki-67/myb, differentiation was assessed by expression of mucin, and apoptosis was evaluated by the TUNEL assay. Spearman correlation analysis was performed on the data, and all P values were two-sided.

RESULTS

All 11 retinoids reversed characteristics associated with the cancerous phenotype in all neoplastic cultures. Glandular structures were observed consistently in retinoid-treated, but not in untreated, OVCAR-3 and Caov-3 cultures. All retinoids decreased growth fractions, and some increased mucin expression. All receptor-independent retinoids and two receptor-dependent retinoids induced apoptosis, and the induction correlated significantly with increased expression of the mucin MUC1 (r =.83; P =.03). Retinoids with ester-linking groups did not induce apoptosis but decreased the growth fraction in correlation with MUC1 induction (r = -.93; P =.02).

CONCLUSIONS

At clinically achievable concentrations, all retinoids tested decrease the growth fraction, induce differentiation and apoptosis. Induction of MUC1 expression is implicated in the mechanisms of action.

Factors affecting fellowship satisfaction among gynecologic oncology fellows

OBJECTIVE

The objective of this study was to determine fellowship satisfaction through a survey of gynecologic oncology fellows.

METHODS

A survey was sent to all gynecologic oncology fellows in May 1998. Surveys were returned anonymously and confidentially. The questions focused on demographics, research and clinical experience, education, faculty involvement, future plans, and fellowship satisfaction. Association between variables were studied using chi(2) and two-tailed t tests.

RESULTS

Of the surveys 53.8% were returned. Reputation, faculty, and clinical diversity were ranked the top three reasons for choosing a fellowship program. Eighty-seven and three-tenths percent were satisfied and 89.1% would recommend their fellowship. Fellows listed the two areas they were most satisfied with as surgical training and research support. Seventy-nine and four-tenths percent agreed they spent adequate time in the operating room and 94.1% had enough variety. Sixty percent or more of the clinical fellows felt they would be uncomfortable performing vaginal radical hysterectomies, splenectomies, radical vaginectomies, laparoscopic lymph node dissection (LND), scalene LND, skin grafts, creation of neovagina, tram flaps, and ureterovaginal fistula repairs by the end of their fellowship. Of the fellows surveyed, 94.7% were currently performing research. All believed they would finish their thesis by the end of their training. Thirty percent of fellows from Gynecologic Oncology Group institutions were not required to participate in their research trials. Among the clinical fellows 62.2% thought time for self-education was lacking compared with 35.3% of the research fellows, P = 0.07. The two areas fellows were least satisfied with were didactics and lack of time for other pursuits. Performance evaluations were received by 72.2%; however, evaluations of the program and of the attending staff occurred in only 51.3 and 34.0%, respectively. Sixty-seven and three-tenths percent stated they had a mentor and 34.0% an advisor. Fellows that did not have mentors or advisors thought they spent less time with faculty in educational pursuits (P = 0.03, 0.06).

CONCLUSION

Areas that could improve fellowship satisfaction include formal didactics and time for self-education. Evaluations of the fellowship and faculty could provide a forum to continue to assess their needs. Requiring a more active role of fellows in research trials may prove to increase research productivity in the future.

Cadet basic training: an ethnographic study of stress and coping

Cadet basic training (CBT) at the U.S. Military Academy at West Point is an initial cadet experience designed to transition freshmen (new cadets) into the military. Challenge is an inherent component of CBT, and some challenging activities may be stressful. However, the nature and the impact of stress on health status have not been systematically investigated. An ethnographic technique, participant observation, was used to identify stressors and coping strategies among cadets aged 18 to 21 years participating in CBT. A company of 183 cadets, consisting of 123 new cadets and 60 supervising upperclass cadets from the U.S. Military Academy, was followed throughout the 6-week CBT in the summer of 1993. The investigator observed daily activities and participated in select field training experiences. Daily field observations were taped, and field notes were generated chronicling the experience. After CBT, 10 of the 60 upperclass cadets participated in a 20-minute structured interview. Field and interview notes were systematically reviewed to identify and categorize stressors and coping techniques. Stressors included anticipatory stress, time management pressures, sleep deprivation, performance evaluations, conflicts between teamwork and competitive grading, and inexperience in the leadership role. Coping techniques identified included perceiving social support, humor, and rationalization. Three new hypotheses were generated from the observations.

Emergency contraception

High rates of adolescent pregnancy remain a challenge for health care providers. For most sexually active adolescents, pregnancy is unintended. Emergency contraception, also called the "morning-after-pill" or postcoital contraception, is a way to prevent pregnancy after unprotected intercourse. In the United States, three forms of emergency contraception currently are available: high-dose combination estrogen and progestin pills, high-dose progestin-only pills, and postcoital insertion of a copper intrauterine device. The postcoital intrauterine device is used infrequently. When emergency contraceptive pills (ECPs) are taken within 72 hours of unprotected intercourse, they reduce the risk of pregnancy by at least 75%. However, they are most effective if taken within 24 hours of coitus. Eleven brands of pills currently are marketed in the United States that conform to the regimens approved by the Food and Drug Administration (FDA) for this indication. Recently, two prepackaged ECPs were approved by the FDA. The only medical contraindication to prescribing ECPs is pregnancy. The most common side effects are nausea and vomiting, followed by menstrual disturbances, breast tenderness, abdominal cramping, dizziness, headache, and mood changes. Because vomiting can compromise the efficacy of ECPs, routine pretreatment with an antiemetic is recommended. Primary care providers can reduce unintended adolescent pregnancy by routinely counseling adolescents at all office visits about the existence of emergency contraception and by prescribing it in advance and over the telephone.

Heteroarotinoids inhibit head and neck cancer cell lines in vitro and in vivo through both RAR and RXR retinoic acid receptors

A class of less toxic retinoids, called heteroarotinoids, was evaluated for their molecular mechanism of growth inhibition of two head and neck squamous cell carcinoma (HNSCC) cell lines SCC-2 and SCC-38. A series of 14 heteroarotinoids were screened for growth inhibition activity in vitro. The two most active compounds, one that contained an oxygen heteroatom (6) and the other a sulfur heteroatom (16), were evaluated in a xenograph model of tumor establishment in nude mice. Five days after subcutaneous injection of 10(7) SCC-38 cells, groups of 5 nu/nu mice were gavaged daily (5 days/week for 4 weeks) with 20 mg/kg/day of all-trans-retinoic acid (t-RA, 1), 10 mg/kg/day of 6, 10 mg/kg/day of 16, or sesame oil. After a few days, the dose of t-RA (1) was decreased to 10 mg/kg/day to alleviate the side effects of eczema and bone fracture. No significant toxic effects were observed in the heteroarotinoid groups. All three retinoids caused a statistically significant reduction in tumor size as determined by the Student t-test (P < 0. 05). Complete tumor regression was noted in 3 of 5 mice treated with t-RA (1), 4 of 5 mice treated with 16, 1 of 5 mice treated with 6, and 1 of 5 mice treated with sesame oil. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to determine that the expression levels of RARalpha, RXRalpha, and RXRbeta were similar in the two cell lines, while RARbeta expression was higher in SCC-2 over SCC-38, and RARgamma expression was higher in SCC-38 over SCC-2. Receptor cotransfection assays in CV-1 cells demonstrated that 16 was a potent activator of both RAR and RXR receptors, while 6 was selective for the RXR receptors. Transient cotransfection assays in CV-1 cells using an AP-1 responsive reporter plasmid demonstrated that t-RA (1), 6, and 16 each inhibited AP-1-driven transcription in this cell line. In conclusion, the growth inhibition activity of the RXR-selective 6 and the more potent growth inhibition activity of the RAR/RXR pan-agonist 16 implicate both RARs and RXRs in the molecular mechanism of retinoid growth inhibition. Moreover, the chemoprevention activity and the lack of toxicity of heteroarotinoids demonstrate their clinical potential in head and neck cancer chemoprevention.

Prescribing and managing oral contraceptive pills and emergency contraception for adolescents

Combination OCPs are safe and effective ways to prevent unintended adolescent pregnancy if they are used properly. Numerous noncontraceptive benefits of OCPs can bolster continued combination OCP use. Progestin-only OCPs are an option, particularly for young women with medical contraindications to taking estrogens; however, because of their lower efficacy, progestin-only pills are not the first choice for oral contraception for adolescents. Health care providers can give young women a second chance to prevent unintended pregnancy by improving their access to emergency contraception through educating and counseling about emergency contraception at all office visits, by prescribing emergency contraceptive pills in advance, or by prescribing emergency contraceptive pills over the telephone.

Large ovarian cellular fibroma during pregnancy mimicking a lipid cell tumor

Lipid cell tumors are extremely rare tumors of the ovary which are usually malignant when larger than eight centimeters. Fibromas, on the other hand, are the most common type of benign ovarian solid tumors. Neither one of these tumors are known to be accelerated by the pregnant state. We report a case of a healthy 15-year-old female who was found to have an ovarian mass during pregnancy. This fibroma weighed more than 3,800 grams and mimicked a lipid cell tumor. Cesarean section and unilateral oophorectomy resulted in a good outcome for both mother and child.

Attitudes of inner-city female adolescents toward medical and surgical abortion

STUDY OBJECTIVE

To explore the attitudes of inner-city minority female adolescents toward medical and surgical abortion to determine if medical abortion methods, which have been shown to be both effective and safe, might have greater appeal than surgical abortion.

DESIGN

A cross-sectional, self-administered survey.

SETTING

The waiting room of an inner-city hospital-based adolescent clinic.

PARTICIPANTS

At total of 157 female adolescents aged 13 to 21 years; Hispanic (56%) and African American (31%). Most (94%) were sexually active, 43% had been pregnant, and 29% had previously had a surgical abortion.

OUTCOME MEASURES

An 86-item questionnaire examining attitudes toward medical and surgical abortion safety and impact on future fertility, and pregnancy, abortion, and sexual history.

RESULTS

A total of 68% believe that abortion is safe, and 55% believe that having an abortion is better than having an unwanted child. Belief in the safety of abortion was significantly associated with older age and with never having had an abortion. Almost three fourths (72%) believe that having an abortion might impair future fertility either from surgical damage (73%) or "as a punishment for having an abortion" (38%). The majority (72%) believe that "the more abortions you have, the harder it will be to get pregnant in the future." Regardless of personal abortion experience, 51% believe that a medical abortion would be safer than a surgical abortion. A minority (34%) believe that it would be easier to get pregnant after a medical abortion than after a surgical one.

CONCLUSIONS

Although most inner-city, minority adolescents believe that abortion is safe, they also believe they risk their future fertility by having an abortion. The availability of medical abortion regimens would greatly influence decisions regarding abortion.

Young women's attitudes toward injectable and implantable contraceptives

STUDY OBJECTIVE

To assess the potential acceptability of implantable and injectable contraceptive characteristics by young women of diverse ethnic and educational backgrounds.

DESIGN

A cross-sectional self-administered survey.

SETTINGS

The waiting room of three clinical sites: an elite women's college health service, a coeducational state university health service, and an inner city hospital-based adolescent clinic.

PARTICIPANTS

328 young women awaiting medical care in one of three clinical sites, aged 13 to 21 years (85% 18-21 years); ethnic distribution differed significantly by site. The majority (83%) were sexually active, and of those who were sexually experienced, 25% had been pregnant.

OUTCOME MEASURES

A 47-item questionnaire examining attitudes toward characteristics of injectable and implantable contraceptive methods, menstrual, sexual, and gynecologic history.

RESULTS

Sixty-two percent of the sample agreed that they would get an injectable method. There was little variation in agreement to get an injectable method by sexual or pregnancy history. Fewer subjects (24%) agreed that they would like to get subdermal implants and agreement to get an implantable method of contraception did not vary by sexual history; however, ever-pregnant young women (33%) were significantly more likely to agree to implants than never-pregnant subjects (21%; chi2, 4.109; p = 0.04). Seventy-four percent of subjects said they would stop using a contraceptive that caused irregular menses, whereas 65% would stop using a method that caused amenorrhea.

CONCLUSIONS

An injectable contraceptive method has universal appeal across ethnic, educational, and age categories, whereas implants are less appealing. Irregular bleeding and amenorrhea are poorly perceived side effects of long-acting contraceptives.

Emergency contraception: a second chance at preventing adolescent unintended pregnancy

Adolescent pregnancy challenges the United States and Europe. For most sexually active adolescents, pregnancy is unintended. Emergency contraception, also called the "morning-after treatment" or postcoital contraception is a way to prevent pregnancy after unprotected intercourse. In February 1997, the Food and Drug Administration (FDA) approved the use of certain oral contraceptive pills for emergency contraception. There are currently six brands of pills marketed in the United States that can be prescribed to, conform to the FDA-approved regimen. When emergency contraceptive pills are initiated within 72 hours of unprotected intercourse, they reduce the risk of pregnancy by 75%. Contraindications are the same as those used for ongoing contraceptive pills. The most common side effects are nausea, vomiting, menstrual disturbances, breast tenderness, abdominal cramping, dizziness, headache, and mood changes. Routinely counseling all adolescents about emergency contraceptive pills and increasing access to them can give adolescents a second chance at preventing pregnancy.

Squamous metaplasia of the endometrium associated with HPV 6 and 11

Although uncommon in the endometrium, squamous metaplasia, dysplasia, and squamous carcinoma have been observed. Associated human papillomavirus (HPV) infection is also unusual, due at least in part to the fact that HPV requires specific characteristics of the target epithelium for infectivity. We report a case of extensive squamous metaplasia with focal low-grade squamous intraepithelial neoplasia of the endometrium coexistent with low-grade cervical intraepithelial neoplasia and an invasive squamous carcinoma of the vagina. In situ hybridization studies revealed HPV types 6 and 11 in both the cervical and endometrial lesions. This is the first report to date to demonstrate squamous epithelial metaplasia and dysplasia of the endometrium, associated with HPV DNA of viruses typically of low oncogenic potential.

Bilateral absence of the ovaries and distal fallopian tubes. A case report

BACKGROUND

Bilateral tuboovarian absence is extremely rare and is associated with infantile sexual development, primary amenorrhea and primary infertility.

CASE

A 23-year-old woman presented for evaluation of primary amenorrhea. Her examination revealed hypoplastic breasts, genitalia and uterus; ovaries could not be identified. Marked estrogen deficiency was confirmed by endocrinologic testing. The karyotype was normal female. The patient was started on combined hormone replacement therapy and subsequently developed normal menses; physical maturation progressed normally. At the age of 29 she underwent diagnostic laparoscopy for evaluation of her fertility potential, at which time the absence of both ovaries and distal fallopian tubes was confirmed.

CONCLUSION

Bilateral tuboovarian absence is an extremely rare cause of primary amenorrhea and is associated with infantile sexual development and primary infertility. Its etiology includes tuboovarian torsion and congenital malformation. In this case, congenital malformation appears to have been the more likely cause.

Emergency contraception: a national survey of adolescent health experts

In a survey of 167 physicians with expertise in adolescent health, 84% said they prescribe contraception to adolescents, but only 80% of these prescribe emergency contraception, generally a few times a year at most. Some 12% of respondents said they believe that providing emergency contraception to adolescents would encourage contraceptive risk-taking, 25% said they think it would discourage correct use of other methods and 29% said they think repeated use of the method could post health risks. Physicians who were more likely than their colleagues to prescribe emergency contraception included obstetrician-gynecologists (92%), those who graduated from medical school after 1970 (77%) and those who describe their practice as being in an "academic" setting (76%). Physicians may restrict use of the method by limiting treatment to adolescents who seek it within 48 hours after unprotected intercourse (29%), by requiring a pregnancy test (64%) or an office visit (68%), or by using the timing of menses as a criterion for providing the method (46%). While 41% of physicians who provide emergency contraception counsel adolescents about the method during family planning visits, only 28% do so during visits for routine health care; 16% counsel women who are not yet sexually active about the method.

Contraception update: implantable and injectable methods

There are currently more options available to pediatricians caring for sexually active adolescents who wish to prevent pregnancy. The two progestin-only methods, levonorgestrel subdermal implants and DMPA injections, minimize or entirely remove the obstacle of patient compliance from contraceptive efficacy. Adolescents considering a progestin-only method of contraception should be counseled explicitly about the likelihood of menstrual irregularity with use. Perhaps more importantly, adolescents should be reminded that hormonal methods of contraception do not provide protection from sexually transmitted disease. Thus, male condom use should not only be recommended, but also concrete discussion and instruction on appropriate use should be given.

Children of gay or lesbian parents

There are no data to suggest that children who have gay or lesbian parents are different in any aspects of psychological, social, and sexual development from children in heterosexual families. There has been fear that children raised in gay or lesbian households will grow up to be homosexual, develop improper sex-role behavior or sexual conflicts, and may be sexually abused. There has been concern that children raised by gay or lesbian parents will be stigmatized and have conflicts with their peer group, thus threatening their psychological health, self-esteem, and social relationships. These fears and concerns have not been substantiated by research. Pediatricians can facilitate the health care and development of these children by being aware of these and their own attitudes, by educating themselves about special concerns of gay or lesbian parents, and by being a resource and an advocate for children who have homosexual parents.

Substance use among adolescents with diabetes mellitus: preliminary findings

Alcohol and drug use frequency was assessed by means of an anonymous, self-administered questionnaire in 79 diabetic adolescents who attended a diabetic sleep away camp. More than half of the participants reported using tobacco or alcohol at least once and 12%-25% reported greater that five times use in their lifetime. The overall frequency of drug and alcohol use was less than the general adolescent population. A modified Michigan Alcohol Screening Test (MAST) was used to evaluate abnormal drinking patterns, and 40%-50% of 12- and 16-year-old campers had an abnormal score, indicating that almost one-quarter of diabetic teens drink dangerously. There was a high correlation between campers who use drugs or alcohol and a positive family history of alcohol or substance abuse. Few campers perceived alcohol or drug use to affect their diabetic control, and the majority believed their control to be good to excellent, thus demonstrating the impact of denial in diabetic adolescent substance use. Adolescent diabetic assessments should include a psychosocial history, with emphasis on patterns of substance use, family substance abuse, and use of the MAST to identify high-risk individuals.

Pressure changes within a chronic subdural hematoma during hemodialysis

Spontaneous intracranial hemorrhage is not an infrequent complication of systemic anticoagulation, as occurs in hemodialysis. The neurological symptoms of subdural hematoma may be similar to those of dialysis disequilibrium. The pressure within a subdural fluid collection was monitored in a patient undergoing hemodialysis. The patient was known to become unresponsive during previous dialysis treatments. The initial pressure within the subdural cavity was measured to be -10.0 cm H2O prior to dialysis. The pressure within the collection decreased to a minimum value of -19.4 cm H2O during dialysis and stabilized at -16.4 cm H2O at the termination of dialysis. The neurological status changed subjectively during the procedure, with the patient becoming unresponsive to verbal stimuli as the intracranial pressure reached a minimum. These findings represent a syndrome similar to aliquorrhea, or low cerebrospinal fluid pressure within an otherwise asymptomatic subdural hematoma. Previously only increased intracranial pressure has been reported with hemodialysis.

Sex differences in specific proteins in the preoptic medial nucleus of the rat hypothalamus

Using two-dimensional gel electrophoresis and a highly sensitive silver stain, specific proteins in adult male and female rat brain were examined. Based on previous studies, the preoptic medial nucleus (POM) of the hypothalamus served as the area of interest, with the parietal cortex acting as control. A significant difference between the sexes was found in the concentration of two proteins in the POM, a difference which was not found in the parietal cortex.