Learning to lead: The evolution of a pilot leadership curriculum for gynecologic oncology fellows at the Ohio State University

•Leadership training is under-emphasized in traditional medical education.•An effective leadership curriculum must be dynamic and requires genuine investment from participants.•Through didactic education, self-reflection, and real-world perspective we can actively mold future leaders in gynecologic oncology.

Does the choice of platinum doublet matter? A study to evaluate the impact of platinum doublet choice for treatment of platinum-sensitive ovarian cancer recurrence on the development of future PARP inhibitor and platinum resistance

OBJECTIVES

The use of a platinum doublet for the treatment of platinum-sensitive epithelial ovarian cancer (EOC) recurrence is well established. The impact of the non‑platinum chemotherapy used as part of a platinum doublet on PARP inhibitor (PARPi) and platinum sensitivity it not known. We aimed to describe oncologic outcomes in cases of recurrent EOC receiving PARPi as maintenance therapy based on preceding platinum doublet.

METHODS

Retrospective study of patients with platinum-sensitive recurrent ovarian, fallopian tube or primary peritoneal cancer treated with platinum doublet followed by maintenance PARPi from 1/1/2015 and 1/1/2022. Comparisons were made between patients receiving carboplatin + pegylated liposomal doxorubicin (CD) versus other platinum doublets (OPDs). Descriptive statistics, Kaplan-Meier and univariate survival analyses were performed.

RESULTS

100 patients received PARPi maintenance following a platinum doublet chemotherapy regimen for platinum-sensitive recurrence. 25/100 (25%) received CD and 75/100 (75%) received OPDs. Comparing CD and OPDs, median progression-free survival was 8 versus 7 months (p = 0.26), median time to platinum resistance was 15 versus 13 months (p = 0.54), median OS was 64 versus 90 months (p = 0.28), and median OS from starting PARPi was 25 versus 26 months (p = 0.90), respectively.

CONCLUSIONS

Using pegylated liposomal doxorubicin as part of a platinum doublet preceding maintenance PARPi for platinum-sensitive recurrence does not seem to hasten PARPi resistance or platinum resistance compared to OPDs. Although there was a non-significant trend towards increased OS among patients who received a platinum doublet other than CD prior to PARPi, the OS from PARPi start was similar between groups. Given the retrospective nature of this study and small study population, further research is needed to evaluate if the choice of platinum doublet preceding PARPi maintenance impacts PARPi resistance, platinum resistance and survival.

Glassy cell carcinoma of the cervix: Findings from a combined National Cancer Database analysis and single institution review of treatment patterns and outcomes

OBJECTIVES

To describe stage, treatment patterns, and survival for glassy cell carcinoma of the cervix (GCCC), a poorly understood rare tumor.

METHODS

Clinical data and survival were compared between GCCC and more common histologic types using the National Cancer Database (NCDB) from 2004 to 2017. A retrospective review of GCCC cases at our institution from 2012 to 2020 was simultaneously performed with staging updated according to 2018 FIGO staging. Descriptive statistics and survival analyses were performed, and outcomes compared to historical references.

RESULTS

143/89,001 (0.16%) NCDB cervical cancer cases were GCCC. Compared to other histologies, GCCC cases were younger, with 74.8% diagnosed before age 50. Stage distribution was similar. Stage I cases were less commonly treated with surgery alone (19/69, 27%). 79.4% of locally advanced (stage II-IVA) cases were treated with definitive chemoradiation. GCCC demonstrated worse OS for early-stage and locally-advanced disease. No survival differences were observed for patients with stage IVB disease. Our institutional review identified 14 GCCC cases. Median age at diagnosis was 34 years. All nine early-stage cases underwent radical hysterectomy. Adjuvant radiation was given for cases meeting Sedlis criteria (4/9, 44%). All five advanced stage cases were stage IIIC and received definitive chemoradiation. Recurrence rate was 0% (0/9) for early-stage and 60% (3/5) for advanced-stage cases. 3-year PFS was 100% for early-stage and 40% for advanced-stage. 3-year OS was 100% for early-stage and 60% for advanced-stage GCCC.

CONCLUSIONS

GCCC presents at earlier ages than other cervical cancer histologic types. Although NCDB showed worse OS, our more contemporary institutional review, which incorporates updated staging and newer treatment modalities found outcomes more similar to historical references of more common histologic subtypes.

Combination lenvatinib plus pembrolizumab in the treatment of ovarian clear cell carcinoma: A case series

Effective second-line treatment options for patients with recurrent ovarian clear cell carcinoma (OCCC) are limited. This case series sought to report tumor characteristics and oncologic outcomes in a small group of patients treated with combination lenvatinib and pembrolizumab. A retrospective analysis of patients with ovarian clear cell carcinoma treated with combination lenvatinib and pembrolizumab at a single institution was performed. Patient and tumor characteristics were collected including demographics and germline/somatic testing. Clinical outcomes were also evaluated and reported. Three patients with recurrent OCCC were included in the study. The median age of patients was 48 years old. All patients had platinum-resistant disease and had received 1-3 prior lines of therapy. The overall response rate was 100% (3/3). Progression-free survival ranged from 10 months to not-yet-reached. One patient remains on treatment, while the other two died of disease with overall survival of 14 and 27 months. Combination lenvatinib-pembrolizumab demonstrated favorable clinical response in these patients with platinum-resistant, recurrent, ovarian clear cell carcinoma.

Use of the Khorana score to predict venous thromboembolism in patients undergoing chemotherapy for uterine cancer

Objective

Gynecologic cancers are associated with a high risk of venous thromboembolism (VTE). The Khorana score is a validated tool to assess risk of VTE in cancer patients. The purpose of this study is to determine if the Khorana score can be used as a risk stratification tool for VTE in patients with uterine cancer undergoing chemotherapy.

Methods

A retrospective cohort study of patients with newly diagnosed uterine cancer receiving chemotherapy over a 4-year period was conducted. The patients were stratified based on their Khorana score as well as their chemotherapy sequence, neoadjuvant or definitive versus adjuvant.

Results

A total of 276 patients were included: 40 received neoadjuvant or definitive, 236 adjuvant chemotherapy. Most patients had advanced stage disease (64.5%). 18 (6.5%) patients developed VTE within 180 days of initiating chemotherapy. High Khorana score was associated with a non-significant increase in VTE (K ≥ 2 OR 1.17, CI 0.40-3.39, K ≥ 3 OR 1.69, CI 0.61-4.69) but had poor predictive accuracy based on area under the curve (K ≥ 2 0.51, K ≥ 3 0.55). The VTE rate was higher in the neoadjuvant/definitive chemotherapy group to adjuvant (12.5% vs 5.5%, p = 0.11). While the former group had a higher average Khorana score (2.35 vs 1.93, p = 0.0048), this was not predictive of VTE.

Conclusions

While validated in other cancer types, the Khorana score was found to be a poor predictor of VTE in patients with uterine cancer. The use of the Khorana score to guide routine thromboprophylaxis in these patients should be used with caution and further investigation is warranted.

Recurrence rate in early-stage epithelial ovarian cancer: Is there a role for upfront maintenance with PARP inhibitors in stages I and II?

Objective

To determine the recurrence rate and survival among early-stage epithelial ovarian cancer cases considering homologous recombination deficiency (HRD) status.

Methods

Single institution retrospective study of stage I/II EOC patients from 2017 to 2020. HRD was defined as evidence of germline or somatic BRCA mutation, or loss of heterozygosity (LOH)/genomic instability (GIS) as determined by companion diagnostic tests. Kaplan-Meier analyses were performed.

Results

89 stage I/II cases were included. 4/89 (4.5%) had a germline BRCA1/2 mutation, 8 (9%) were germline negative but had a somatic BRCA mutation, and 8 (9%) were BRCA wild-type but had evidence of LOH/GIS on somatic testing; these 20/89 (22%) cases comprised the HRD group. The remaining tumors were confirmed homologous recombination proficient (HRP, 35/89, 39%) or homologous recombination unknown (HRU, 34/89, 38%). The overall recurrence rate was 33/89 (37%). There were more recurrences among HRD cases (14/20, 70%) compared to HRP/HRU cases (19/69, 27.5%, p = 0.0012). Median Recurrence-Free Survival (RFS) was 35 months for HRD cases and 225 months for HRP/HRU cases (p = 0.001). At 2 years, there were 60% HRD cases and 88% HRP/HRU cases recurrence-free. At 5 years there were 29% HRD and 69% HRP/HRU cases recurrence-free (p = 0.001).

Conclusions

Despite a high rate of complete surgical staging and six cycles of adjuvant chemotherapy, recurrence rate was high in this early-stage cohort. Higher recurrence rates were seen in the HRD group, however these data are likely biased by the clinical practice of tumor testing primarily at the time of recurrence rather than the upfront setting. RFS was significantly lower for HRD cases.

The modified 5-item frailty index is a predictor of post-operative complications in vulvar cancer: a National Surgical Quality Improvement Program (NSQIP) analysis

OBJECTIVE

To determine whether frailty is associated with post-operative complications following surgery for vulvar cancer.

METHODS

This retrospective study used a multi-institutional dataset from the National Surgical Quality Improvement Program (NSQIP) database (2014-2020) to analyze the relationship between frailty, procedure type, and post-operative complications. Frailty was determined using the modified frailty index-5 (mFI-5). Univariate and multivariable-adjusted logistic regression analyses were performed.

RESULTS

Of 886 women, 49.9% underwent radical vulvectomy alone, and 19.5% and 30.6% underwent concurrent unilateral or bilateral inguinofemoral lymphadenectomy, respectively; 24.5% had mFI ≥2 and were considered frail. Compared with non-frail women, those with an mFI ≥2 were more likely to have an unplanned readmission (12.9% vs 7.8%, p=0.02), wound disruption (8.3% vs 4.2%, p=0.02), and deep surgical site infection (3.7% vs 1.4%, p=0.04). On multivariable-adjusted models, frailty was a significant predictor for minor (OR 1.58, 95% CI 1.09 to 2.30) and any complications (OR 1.46, 95% CI 1.02 to 2.08). Specifically, for radical vulvectomy with bilateral inguinofemoral lymphadenectomy, frailty was significantly associated with major (OR 2.13, 95% CI 1.03 to 4.40) and any complications (OR 2.10, 95% CI 1.14 to 3.87).

CONCLUSION

In this analysis of the NSQIP database, nearly 25% of women undergoing radical vulvectomy were considered frail. Frailty was associated with increased post-operative complications, especially in women concurrently undergoing bilateral inguinofemoral lymphadenectomy. Frailty screening prior to radical vulvectomy may assist in patient counseling and improve post-operative outcomes.

Gastritis as an immunotherapy-related toxicity in the treatment of endometrial cancer: a case report

Gastritis related to immunotherapy use is a less commonly reported adverse effect. With increasing use of immunotherapy agents in the management of patients with endometrial cancer, even rare adverse effects are being seen more frequently in gynecologic oncology practice. A 66-year-old with recurrent mismatch repair deficient endometrial cancer was treated with single-agent pembrolizumab. She initially appeared to tolerate treatment well; however after 16 months of therapy she began to develop nausea, vomiting, and abdominal pain that resulted in 30-pound weight loss. Pembrolizumab was held out of concern for immunotherapy related toxicity. She underwent evaluation with gastroenterology including esophagogastroduodenoscopy (EGD) with biopsy that demonstrated severe lymphocytic gastritis. She was treated with IV methylprednisolone with improvement in symptoms over three days. She was then transitioned to oral prednisone at 60 mg daily with weekly taper by 10 mg, with a proton pump inhibitor (PPI) and carafate until resolution of symptoms. She subsequently had a follow up EGD with biopsy, which demonstrated resolving gastritis. She is presently doing well off of steroids with stable disease noted on her last scan after cessation of pembrolizumab.

The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes

OBJECTIVE

The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy.

METHODS

This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used.

RESULTS

We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5).

CONCLUSION

This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

The interaction between depression diagnosis and BMI is related to altered activation pattern in the right inferior frontal gyrus and anterior cingulate cortex during food anticipation

BACKGROUND

Depression and overweight/obesity often cooccur but the underlying neural mechanisms for this bidirectional link are not well understood.

METHODS

In this functional magnetic resonance imaging study, we scanned 54 individuals diagnosed with depressive disorders (DD) and 48 healthy controls (HC) to examine how diagnostic status moderates the relationship between body mass index (BMI) and brain activation during anticipation and pleasantness rating of food versus nonfood stimuli.

RESULTS

We found a significant BMI-by-diagnosis interaction effect on activation in the right inferior frontal gyrus (RIFG) and anterior cingulate cortex (ACC) during food versus nonfood anticipation (p < .0125). Brain activation in these regions was greater in HC with higher BMI than in HC with lower BMI. Individuals with DD showed an opposite pattern of activation. Structural equation modeling revealed that the relationship between BMI, activation in the RIFG and ACC, and participants' desire to eat food items shown in the experiment depended on the diagnostic status.

CONCLUSIONS

Considering that food anticipation is an important component of appetitive behavior and that the RIFG and ACC are involved in emotion regulation, response inhibition and conflict monitoring necessary to control this behavior, we propose that future clinical trials targeting weight loss in DD should investigate whether adequate mental preparation positively affects subsequent food consumption behaviors in these individuals.

Implementing universal upfront multi-gene panel testing in endometrial cancer: From cost to practical considerations

OBJECTIVES

The routine use of upfront universal germline genetic testing among patients with newly diagnosed endometrial cancer (EC) has been proposed to improve diagnosis of Lynch syndrome (LS) and discover pathogenic variants (PVs) in other cancer susceptibility genes. We propose an algorithm prioritizing upfront multi-gene panel testing (MGPT) for newly diagnosed EC patients.

METHODS

A decision analysis compared the cost of the current algorithm of universal mismatch repair (MMR) immunohistochemistry (IHC) for all EC cases to a new MGPT algorithm that employs upfront MGPT for all EC cases and reserves MMR IHC for the recurrent setting. The increase in the number of LS diagnoses using upfront MGPT, and the number of patients with PVs in BRCA1 and BRCA2 are also estimated.

RESULTS

The MGPT algorithm demonstrated a cost savings of $259 per patient. Assuming 66,950 new cases of EC per year, this would represent $17.1 M of cost savings per year. When applied to all new diagnoses of EC in one year, the MGPT algorithm identified 660 (1%) additional cases of LS that would have been missed with the current algorithm. An additional 660 (1%) EC patients with BRCA1 or BRCA2 PVs would be diagnosed only through implementation of universal MGPT.

CONCLUSIONS

The use of universal upfront MGPT is a practical consideration for patients with newly diagnosed EC for cost savings and improved diagnosis of highly penetrant cancer syndromes. Incorporation of germline genetic testing in the upfront setting represents an opportunity to improve access to genetic counseling and testing, and ultimately an avenue to achieve equity and improve the lives of our patients with EC and their families.

Up-Front Multigene Panel Testing for Cancer Susceptibility in Patients With Newly Diagnosed Endometrial Cancer: A Multicenter Prospective Study

PURPOSE

Clinical utility of up-front multigene panel testing (MGPT) is directly related to the frequency of pathogenic variants (PVs) in the population screened and how genetic findings can be used to guide treatment decision making and cancer prevention efforts. The benefit of MGPT for many common malignancies remains to be determined. In this study, we evaluated up-front MGPT in unselected patients with endometrial cancer (EC) to determine the frequency of PVs in cancer susceptibility genes.

METHODS

Patients with EC were prospectively enrolled at nine Ohio institutions from October 1, 2017, to December 31, 2020. Nine hundred and sixty-one patients with newly diagnosed EC underwent clinical germline MGPT for 47 cancer susceptibility genes. In addition to estimating the prevalence of germline PVs, the number of individuals identified with Lynch syndrome (LS) was compared between MGPT and tumor-based screening.

RESULTS

Likely pathogenic variants or PVs were identified in 97 of 961 women (10.1%). LS was diagnosed in 29 of 961 patients (3%; 95% CI, 2.1 to 4.3), with PVs in PMS2 most frequent. MGPT revealed nine patients with LS in addition to the 20 identified through routine tumor-based screening. BRCA1 and BRCA2 PVs were found in 1% (10 of 961; 95% CI, 0.6 to 1.9) of patients and that group was significantly enriched for type II ECs.

CONCLUSION

This prospective, multicenter study revealed potentially actionable germline variants in 10% of unselected women with newly diagnosed EC, supporting the use of up-front MGPT for all EC patients. The discovery that BRCA1 or BRCA2 heterozygotes frequently had type II cancers points to therapeutic opportunities for women with aggressive histologic EC subtypes.

Outcomes of Minimally Invasive versus Open Radical Hysterectomy for Early Stage Cervical Cancer Incorporating 2018 FIGO Staging

STUDY OBJECTIVE

To compare outcomes after minimally invasive surgery (MIS) vs open radical hysterectomy for early stage cervical cancer incorporating 2018 Federation of Gynecology and Obstetrics (FIGO) staging.

DESIGN

A retrospective analysis.

SETTING

A single teaching hospital.

PATIENTS

Patients after radical hysterectomy for stage IA1 with lymphovascular invasion, IA2, or IB1 squamous, adenosquamous, or adenocarcinoma of the cervix between 2007 and 2018, mirroring the Laparoscopic Approach to Cervical Cancer trial criteria.

INTERVENTIONS

The use of MIS surgery for performing radical hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The outcomes were compared between patients undergoing MIS vs open approaches. A total of 126 patients met the inclusion criteria. The approach was open in 44 patients (35%) and MIS in 82 patients (65%); 49% were laparoscopic and 51% were robotic. Distribution based on the 2009 FIGO staging showed 1 stage IA1 with lymphovascular invasion, 15 stage IA2, and 110 stage IB1 patients. Although not statistically significant, the 3-year disease-free survival (DFS) was higher in the open compared to the MIS group (95% vs 87%; p = .17), and the overall survival was higher in the open compared to the MIS group (97% vs 92%; p = .25). Fourteen patients whose disease recurred were Stage IB1 by FIGO 2009 staging; 11/14 were reclassified to a higher stage by 2018 FIGO staging (5/5 open, 6/9 MIS). Adjuvant therapy was recommended for all these patients based on the Sedlis criteria (10/14) or other risk factors (4/14). Despite this, only 1/9 of MIS patients whose disease recurred received adjuvant therapy compared with 3/5 patients whose disease recurred in the open group (p = .05).

CONCLUSION

In a cohort of patients similar to that of the Laparoscopic Approach to Cervical Cancer trial, 2018 FIGO staging may be useful to refine indications for MIS radical hysterectomy in early stage cervical cancer. However, disparate outcomes between MIS and open approaches may be explained by differences in compliance with National Comprehensive Cancer Network guidelines for adjuvant therapy.

Preoperative lifestyle intervention in bariatric surgery: initial results from a randomized, controlled trial

OBJECTIVE

To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance-mandated physician supervised diet).

DESIGN AND METHODS

After completing a baseline assessment, candidates for surgery were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses.

RESULTS

LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001-1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory).

CONCLUSIONS

A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

Visual information processing in primate cone pathways. I. A model

At the retinal level, the strategies utilized by biological visual systems allow them to outperform machine vision systems, serving to motivate the design of electronic or "smart" sensors based on similar principles. Design of such sensors in silicon first requires a model of retinal information processing which captures the essential features exhibited by biological retinas. In this paper, a simple retinal model is presented, which qualitatively accounts for the achromatic information processing in the primate cone system. The computer retina model exhibits many of the properties found in biological retinas such as data reduction through nonuniform sampling, adaptation to a large dynamic range of illumination levels, variation of visual acuity with illumination level, and enhancement of spatiotemporal contrast information. The main emphasis of the model presented here is to demonstrate how different adaptation mechanisms play a role in extending the operating range of the primate retina.

Do changes in mood and concerns about weight relate to smoking relapse in the postpartum period?

The majority of women who quit smoking during pregnancy will resume smoking during the postpartum period. Little is known, however, about the predictors of postpartum relapses to smoking. Changes in mood and increases in concerns about weight are common during the postpartum period, and these factors may affect women's postpartum smoking behavior. In this paper, we present a model of the relationship among mood, weight concerns and postpartum smoking. Data from previous postpartum relapse prevention trials are reviewed and evidence of a connection between changes in mood and weight concerns to postpartum relapse is presented. Directions for future research on the prevention of smoking relapses during the postpartum period, and the roles of mood and weight concerns in smoking relapse are presented.

Is family-based behavioral weight control appropriate for severe pediatric obesity?

OBJECTIVE

Although the efficacy of family-based behavioral treatment for moderate pediatric obesity has been well established, few studies have focused on the treatment of severe obesity. We sought to evaluate the acceptability and feasibility of a family-based intervention for severely obese children.

METHOD

Twenty-four families with children aged 8-12 years who were > or =160% of their ideal body weight participated in a 10-12-session behavioral intervention. Participants were weighed and their heights measured at the start of each treatment session and during a follow-up visit 4-13 (M = 7.8) months posttreatment. Children also completed measures of depressive symptoms and anxiety at pretreatment, posttreatment, and follow-up, and eating attitudes were assessed at pretreatment and follow-up.

RESULTS

One third of the families did not complete treatment. However, children who completed the program lost a significant amount of weight and reported significant improvements in depression, anxiety, and eating attitudes that were maintained over time.

DISCUSSION

A short-term, family-based behavioral intervention was successful in moderating weight gain for most children and had positive effects on children's mood and eating disorder symptoms. Future randomized, controlled trials of longer interventions are necessary to determine the success of this approach.

Attentional function as measured by a Continuous Performance Task in children with dyscalculia

This study determined whether or not students with dyscalculia had difficulty with attention as measured by the Conners' Computerized Continuous Performance Test (CPT). Fifty-six control subjects and 27 subjects with dyscalculia were administered the CPT. Performance was measured using percent omission errors, percent commission errors, mean response time, SE of response times (SE-RT), and a calculated overall attention index (CPT Index). Compared with controls, subjects with dyscalculia had higher CPT Index scores, made more omission errors, and had more inconsistent response times (SE-RT). Multiple regression analysis of arithmetic scores showed that SE-RT and percent commission errors were the only CPT measures that contributed to the arithmetic scores. Problems with attention, as measured by the Conners' CPT, were associated with lower arithmetic achievement scores. Students who have difficulties in arithmetic may have more attentional problems than other children, and students with attentional difficulties may be at risk for difficulties in arithmetic.

The characteristics of women smokers concerned about postcessation weight gain

Concern about weight gain after quitting smoking is common among women, however, little is known about the characteristics of women concerned about this weight gain. We characterized concerns about smoking and weight, smoking behaviors and eating attitudes among weight-concerned women smokers. Women (N= 219) were participants in a larger trial comparing different approaches to treating postcessation weight gain concerns, and endorsed considerable concern about postcessation weight gain. Women completed assessments of smoking behavior, nicotine dependence and eating attitudes prior to beginning treatment. Although weight-concerned women smokers expected to gain 16.5 lb after quitting, most were willing to tolerate a weight gain of only 5 lb. A substantial number expressed unwillingness to gain any weight at all. However, weight-concerned women did not have elevated nicotine dependency or aberrant eating attitudes. Thus, although weight-concerned women smokers expected to gain large amounts of weight after quitting, they expressed a willingness to tolerate only minimal weight gain. The discrepancy between expected and tolerable weight gain may undermine efforts to quit smoking in this group of women.

Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women

Women smokers concerned about weight gain (N = 219) were randomly assigned to 1 of 3 adjunct treatments accompanying group smoking cessation counseling: (a) behavioral weight control to prevent weight gain (weight control); (b) cognitive-behavioral therapy (CBT) to directly reduce weight concern, in which dieting was discouraged; and (c) standard counseling alone (standard), in which weight gain was not explicitly addressed. Ten sessions were conducted over 7 weeks, and no medication was provided. Continuous abstinence was significantly higher at posttreatment and at 6 and 12 months of follow-up for CBT (56%, 28%, and 21%, respectively), but not for weight control (44%, 18%, and 13%, respectively), relative to standard (31%, 12%, and 9%, respectively). However, weight control, and to a lesser extent CBT, was associated with attenuation of negative mood after quitting. Prequit body mass index, but not change in weight or in weight concerns postquit, predicted cessation outcome at 1 year. In sum, CBT to reduce weight concerns, but not behavioral weight control counseling to prevent weight gain, improves smoking cessation outcome in weight-concerned women.

Eating behavior following stress in women with and without bulimic symptoms

OBJECTIVE

This study examined the effects of an interpersonal stressor on subsequent calorie intake in females with (N = 20) and without (N = 20) significant bulimic symptomatology.

METHOD

Subjects participated in two laboratory sessions that differed according to experimental condition (stress versus no stress), completed self-report measures of mood and anxiety before and after the experimental task, and were provided with an array of snack foods after each session.

RESULTS

Counter to the hypothesis, women with bulimic symptoms did not differentially increase their intake when exposed to stress. However, results for the intake of each macronutrient indicated that both bulimic and control women increased their consumption of carbohydrates following the stressor. Thus, stress was related to increased carbohydrate consumption by all subjects but did not differentially affect the consumption of women with bulimic symptoms.

CONCLUSIONS

It may be that women with bulimic symptoms are not differentially vulnerable to eating in response to stress or that current laboratory paradigms are unable to detect differences in eating following a stressor.

Addressing women's concerns about weight gain due to smoking cessation

Specific concerns about weight gain following smoking cessation inhibit attempts to quit smoking, especially in women. However, adjunct interventions to prevent weight gain after cessation have generally been successful only in attenuating, rather than preventing, weight gain. More aggressive weight control adjuncts may be necessary to prevent cessation-induced weight gain. On the other hand, weight control programs have not been found to improve long-term smoking abstinence and, in fact, may actually impede abstinence, necessitating a search for alternative approaches to addressing weight concerns. Since the typical amount of weight gain is essentially trivial from a health standpoint, particularly when compared with the health benefits of quitting smoking, the most appropriate clinical strategy may be to combat the weight concerns themselves rather than the weight gain. A second alternative approach is to focus all treatment efforts on smoking cessation alone, to avoid placing excessive burdens on participants resulting from attempting simultaneous changes in multiple health behaviors (i.e., smoking and those related to weight). The rationales for these three clinical approaches to addressing concerns about weight gain-more effective weight control, direct reduction in weight concerns by cognitive-behavioral treatment, and smoking cessation only-are presented, followed by descriptions of the adjunct treatments based on these approaches currently being evaluated in a clinical outcome study with women trying to quit smoking.

Exercise in the treatment of binge eating disorder

OBJECTIVE

In this study, we examined the effects of an exercise intervention in the treatment of obese women with binge eating disorder (BED).

METHOD

Subjects were randomized to one of two 6-month treatment programs that included an identical exercise component (n = 44) or to a delayed treatment control condition (n = 33). Exercise level, binge eating frequency, and depressive symptomatology were assessed pre- and posttreatment.

RESULTS

Women who received active treatment reported significantly greater increases in their weekly exercise frequency than did control subjects. At posttreatment, 81.4% of subjects who had received treatment were abstinent from binge eating. Compared to women who were not abstinent at posttreatment, abstinent women evidenced significant changes in exercise frequency and caloric expenditure. However, weight loss and improvements in depressive symptomatology were not related to exercise participation.

DISCUSSION

These results suggest that exercise may be an important aspect of BED treatment and useful in promoting abstinence from binge eating.

Stimulation and regulation of tumor cell motility in invasion and metastasis

In this review, the role of extracellular factors in the stimulation and regulation of tumor cell motility are discussed. Tumor cells respond in a motile fashion to a variety of external ligands including autocrine motility factors, growth factors, and components of the extracellular matrix. Since tumor cell motility is a necessary component of tumor invasion and metastasis, we speculate that these protein factors could play important regulatory roles in tumor motility at different stages of the metastatic cascade.

Live cell image segmentation

A major requirement of an automated, real-time, computer vision-based cell tracking system is an efficient method for segmenting cell images. The usual segmentation algorithms proposed in the literature exhibit weak performance on live unstained cell images, which can be characterized as being of low contrast, intensity-variant, and unevenly illuminated. We propose a two-stage segmentation strategy which involves: 1) extracting an approximate region containing the cell and part of the background near the cell, and 2) segmenting the cell from the background within this region. The approach effectively reduces the influence of peripheral background intensities and texture on the extraction of a cell region. The experimental results show that this approach for segmenting cell images is both fast and robust.

Talkative children: verbal fluency as a marker for problematic peer relationships in clinic-referred children with attention deficits

The relationships between attention deficits, hyperactivity, neurodevelopmental performance, and problematic peer relationships were examined in 99 consecutive children (ages 9 to 11 years) referred for school problems to a clinic. Using a teachers' rating scale, 32 children with cognitive inattention and a comparison group of 67 children without cognitive inattention were identified. The former group comprised children who met criteria for Attention Deficit-Hyperactivity Disorder (ADHD). The latter group comprised children with learning disorders and school problems, 42 of whom did not meet criteria for ADHD. Analysis indicated that the study group had greater peer problems, as estimated by teachers' ratings, than the comparison group. Cognitive inattention was related to peer problems over and above the effects of hyperactivity. Neurodevelopmental predictors of peer problems were different among children with ADHD and those without ADHD. Among children with ADHD, proficiency in tasks of verbal fluency was significantly predictive of peer problems. These preliminary findings suggest that children showing teacher-rated cognitive inattention also manifest significant peer problems and that the presence of strong verbal fluency may make these children prone to inappropriate excessive talking and, subsequently, to alienation of peers.

The wrath of math. Deficiencies of mathematical mastery in the school child

Mastery of mathematics involves the interactions of multiple developmental pathways. Children with mathematics disabilities often experience profound feelings of intellectual inadequacy that can erode self-esteem and academic motivation. This article delineates 16 interactive subcomponents that students who underachieve in mathematics can encounter. The article also discusses assessment and management issues for children with mathematics disabilities.

A study of the cognitive aspects of sexual decision making in adolescent females

A comprehensive sexuality questionnaire was administered to 37 females, ages 13 through 16 years, who attended clinics for routine health care. Subjects completed standardized scales of self-concept, locus of control, and future orientation. They also were given a short battery of standardized cognitive tests. Three groups were identified: Group 1 was sexually active and using contraception reliably, Group 2 was not using contraception reliably, and Group 3 had not been sexually active. Group 1 adolescents had higher scores on the vocabulary subtest of the WISC-R (F = 3.4, p less than .05) than did Group 2 adolescents, over and above the effect of socioeconomic status (SES). Group 1 subjects had higher scores on knowledge of sex and contraception than did Group 2 (F = 3.3, p less than .05). Group 1 had more internal locus of control (F = 7.0, p less than .005) than did Group 2 over and above the effect of SES. Mean scores for Group 3 adolescents were intermediate and not significantly different. The findings suggest that cognitive factors may influence contraceptive behavior in adolescent females.

Neurodevelopmental study of writing disorders in middle childhood

This study investigated patterns of neurodevelopmental dysfunction in children with writing disorders (WD). Records of children, ages 9 to 15 years, referred to a school problems clinic were examined. Using teacher questionnaire information, including ratings of writing legibility, mechanics, rate, linguistic sophistication, and spelling, 99 cases of WD were found. Sixty-three children without WD served as clinic controls. A cluster analysis revealed four discrete subtypes of WD and two non-WD control clusters. The four WD clusters were found to have different patterns of writing and reading characteristics. Neurodevelopmental tests discriminated among the clusters (F = 2.8, p less than .0001), and an examination of neurodevelopmental performance characteristics among the clusters showed different patterns of strengths and weaknesses. An empirically derived subtyping of WD is proposed: WD with fine motor and linguistic deficits, WD with visual-spatial deficits, WD with attention and memory deficits, and WD with sequencing deficits. This subtyping, if confirmed in a population study, may have important diagnostic and therapeutic implications.

Ice Flexure Forced by Internal Wave Packets in the Arctic Ocean

Tiltmeters on the Arctic Ocean were used to measure flexure of the ice forced by an energetic packet of internal waves riding the crest of diurnal internal bores emanating from the Yermak Plateau, north of the Svalbard Archipelago. The waves forced an oscillatory excursion of 36 microradians in tilt of the ice, corresponding to an excursion of 16 micrometers per second in vertical velocity at the surface and of 3.5 millimeters in surface displacement. Strainmeters embedded in the ice measured an excursion of 3 x 10(-7) in strain, consistent with ice flexure rather than compression. The measured tilt is consistent with direct measurements of excursions in horizontal current near the surface (12 centimeters per second) and in vertical displacement (36 meters) of the pycnocline 100 meters below the surface.

Neurodevelopmental readiness for adolescence: studies of an assessment instrument for 9- to 14-year-old children

The Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID) is a neurodevelopmental examination for 9- to 14-year-old children. The examination was designed largely for use by developmental-behavioral pediatricians as a way of assessing certain critical developmental functions, including attention, memory, language, and motor coordination in children with school problems. Preliminary field testing of the PEERAMID was carried out in one community, and subsequently a revised version was standardized on randomly selected subjects from three communities near Boston, Massachusetts, and on groups of children from those towns said to be having significant problems at school. Additionally, the examination was used for the evaluation of 106 consecutive patients referred to the School Function Program at The Children's Hospital in Boston. Statistically significant performance differences discriminated between children with normal academic performance and those with school problems in the community as well as in the referral setting. It was discovered that children with school problems tended to have clusters of dysfunction, whereas normally achieving youngsters more often harbored no developmental dysfunctions or perhaps one or two areas of difficulty. It is believed that the PEERAMID can be a useful instrument in serving as part of a pediatric contribution to a multidisciplinary assessment in children in this age group.

A follow-up study of preschool children evaluated for developmental and behavioral problems

Parents and teachers of preschool children evaluated for developmental and behavioral problems in a tertiary pediatric clinic were surveyed an average of 15 months after the initial visit to determine whether they thought the original presenting problem(s) were still present. In 46 percent of cases in which there was an initial concern about behavior, parents continued to be concerned. In contrast, only 24 percent of responding parents continued to be concerned about developmental problems. In more than half of the cases in which parents were no longer concerned, especially about behavior, teachers indicated that there continued to be problems. Age and sex of children were not related to outcome. The higher the socioeconomic status of parents, the more likely the parents were to report persistent developmental problems. Children with persistent problems tended to have difficult temperament characteristics. This study suggests that it is difficult to predict which problems will persist and that there are varying viewpoints as to the nature and existence of these problems.

Multiple resolution skeletons

This paper presents a new algorithm to compute skeletons of noisy images of objects which can be described as ``amorphous blobs.'' Such a requirement arose from our research to obtain a better understanding of the role of the pseudopod in leukocyte locomotion. It involves the modeling and detection of pseudopods which are by their nature nonrigid bodies appearing on the cell's surface membrane. By computing skeletons at different resolutions, a filtered version can be produced without violating the constraints imposed by the semantic knowledge of pseudopod morphology. The filtered version incorporates all the significant ``events'' that occur at the different resolutions. The resolution at which the shape is examined is related to the degree of smoothing, in that the lower the resolution gets, the higher the degree of smoothing. Skeleton branches that persist over several scales arise from convexities that are locally as well as globally significant. Their stability is related to their perceptual significance. Our approach is to combine an initial region centered description (skeleton) with a boundary analysis executed at different resolutions. Having computed the skeleton at different scales, we then use those computed at the lower resolutions as a measure of how global the underlying convexity is. Clearly the skeletons computed at higher resolutions represent the exact location and orientation of the underlying convexities.

Targeted early childhood programming. The promise half fulfilled

A group of 169 children was followed up from birth to second grade in a community-based early identification and early intervention project. Periodic assessments of health and function yielded profiles of concerns. Over the first five years of life, 39% of the children had health concerns, 20% had cognitive concerns, 25% had motor concerns, 15% had social adjustment problems, and 12% had early attentional problems. Children at the highest risk of having reading and behavioral problems in second grade were those with early attentional disability. At the second-grade level, 31% of the children with early attention concerns were one full grade behind in reading and 38% had behavioral problems; among the youngsters without early attentional concerns, 6% demonstrated a reading delay and 8% had behavioral problems. In addition, children of highly educated mothers were more likely to benefit from the multidisciplinary program than were children of less educated mothers, for whom the intervention effected only a modest improvement when contrasted with randomly selected comparison children. For instance, among children with early cognitive problems and whose mothers had little education, 31% of these children had reading problems in second grade as opposed to 10% of those whose mothers had high educational attainment. Similarly, 39% of children with the combined risks of low maternal education and early attentional problems had reading problems in second grade compared with none of the attention-problem children of highly educated mothers. This study shows that while early identification of health and developmental problems can be carried out in a community-based project, strategies for the early intervention of developmental concerns among children of low socioeconomic status remain less than completely effective.