Exploring sex differences in trajectories of pubertal development and mental health following early adversity

Despite evidence that early life adversity (ELA) affects mental health in adolescence, we know little about sex differences in how distinct dimensions of adversity affect development and their corresponding effects on mental health. In this three-wave longitudinal study, 209 participants (118 females; ages 9-13 years at baseline) provided objective (salivary hormones, BMI, age of menarche) and subjective (perceived gonadal and adrenal status) measures of puberty and physical development, and reported on levels of internalizing and externalizing symptoms at all timepoints. Participants also reported lifetime exposure to three distinct types of ELA: deprivation, threat, and unpredictability. Using generalized additive mixed models, we tested within each sex whether dimensions of adversity were associated with longitudinal changes in measures of pubertal and physical development, and whether these indices of development were associated with trajectories of internalizing and externalizing symptoms. In females, experiences of threat and unpredictability were significantly associated with earlier pubertal timing (e.g., age of menarche) whereas experiences of deprivation were associated with steeper increases in BMI; further, faster pubertal tempo (i.e., steeper increases in pubertal stage) was associated with increases in internalizing and externalizing symptoms. In males, however, ELA was not associated with any measures of pubertal or physical development or with symptoms. Together, our results suggest that adverse experiences during early life have sex-selective consequences for pubertal and physical maturation and mental health trajectories in ways that may elucidate why females are at higher risk for mental health difficulties during puberty, particularly following exposure to unpredictable and threatening experiences of adversity.

Sex-Specific Vulnerability to Externalizing Problems: Sensitivity to Early Stress and Nucleus Accumbens Activation Over Adolescence

BACKGROUND

Exposure and sensitivity to early-life stress (ELS) are related to increased risk for psychopathology in adolescence. While cross-sectional studies have reported blunted nucleus accumbens (NAcc) activation in the context of these associations, researchers have not yet assessed the effects of ELS on developmental trajectories of activation. We examined whether trajectories are affected by stress and the moderating role of biological sex in predicting vulnerability to symptoms of psychopathology.

METHODS

Adolescents (n = 173) completed 3 assessments at 2-year intervals across puberty (ages 9-18 years). At baseline, we assessed objective ELS and stress sensitivity using the Traumatic Events Screening Inventory for Children. At all time points, we assessed NAcc activation using the Monetary Incentive Delay task and externalizing, internalizing, and total problems using the Youth Self-Report. We examined correlations between NAcc trajectories (extracted using linear mixed-effects models) with ELS and stress sensitivity and conducted multivariate regression analysis to examine the interaction of NAcc trajectories and biological sex in predicting symptoms of psychopathology.

RESULTS

Symptoms increased over adolescence. Stress sensitivity, but not objective ELS, was associated with decreasing trajectories of NAcc activation. Biological sex interacted with NAcc trajectories to predict psychopathology; boys, but not girls, with decreasing NAcc activation had more severe externalizing problems in adolescence. These findings were replicated in the putamen and caudate but not in the medial prefrontal cortex or control brain regions.

CONCLUSIONS

NAcc activation may be a sex-specific marker of externalizing problems in adolescence. Efforts to reduce stress sensitivity may help to decrease symptoms of psychopathology in adolescent boys.

The default mode network is associated with changes in internalizing and externalizing problems differently in adolescent boys and girls

Internalizing and externalizing problems that emerge during adolescence differentially increase boys' and girls' risk for developing psychiatric disorders. It is not clear, however, whether there are sex differences in the intrinsic functional architecture of the brain that underlie changes in the severity of internalizing and externalizing problems in adolescents. Using resting-state fMRI data and self-reports of behavioral problems obtained from 128 adolescents (73 females; 9-14 years old) at two timepoints, we conducted multivoxel pattern analysis to identify resting-state functional connectivity markers at baseline that predict changes in the severity of internalizing and externalizing problems in boys and girls 2 years later. We found sex-differentiated involvement of the default mode network in changes in internalizing and externalizing problems. Whereas changes in internalizing problems were associated with the dorsal medial subsystem in boys and with the medial temporal subsystem in girls, changes in externalizing problems were predicted by hyperconnectivity between core nodes of the DMN and frontoparietal network in boys and hypoconnectivity between the DMN and affective networks in girls. Our results suggest that different neural mechanisms predict changes in internalizing and externalizing problems in adolescent boys and girls and offer insights concerning mechanisms that underlie sex differences in the expression of psychopathology in adolescence.

Negative caregiving and stress reactivity moderate the relation between early life stress and externalizing in adolescence

Exposure to early life stress (ELS) is common and has been implicated in the development of psychopathology; importantly, however, many individuals who experience ELS do not develop emotional or behavioral difficulties. Prior research implicates stress exposure, negative caregiving behaviors, and patterns of physiological reactivity in predicting psychological well-being; however, the precise factors that contribute to resilience versus vulnerability to the adverse effects of stress exposures are not well understood. In a longitudinal study of adolescents (N = 120) assessed at three timepoints approximately every 2 years beginning at the ages of 913 years, we examined the roles of autonomic reactivity to social stress (assessed through skin conductance during the Trier Social Stress Task) and negative caregiving behaviors as moderators of the association between exposure to ELS and internalizing and externalizing symptoms. We found that the relation between ELS and externalizing symptoms was moderated by both negative caregiving and autonomic reactivity, such that the relation between ELS and externalizing was positive at low levels of negative caregiving and at high levels of autonomic reactivity; interactions predicting internalizing symptoms were not statistically significant. These findings highlight the importance of considering physiological and environmental variables that might contribute to susceptibility or resilience to symptoms of psychopathology following exposure to ELS.

Early life stress, systemic inflammation, and neural correlates of implicit emotion regulation in adolescents

Exposure to early life stress (ELS) increases the risk for developing psychopathology; however, the mechanisms underlying this association are not clear. In this study we examined systemic inflammation as a pathway that may link exposure to stress to altered neural correlates of implicit emotion regulation in adolescents with varying levels of exposure to ELS (n = 83; 52 females, 31 males; 15.63 ± 1.10 years). We measured ventrolateral prefrontal cortex (vlPFC) activation and functional connectivity (FC) between the bilateral amygdala and the vlPFC as adolescents completed an affect labeling task in the scanner and assessed concentrations of C-reactive protein (CRP) using a dried blood spot protocol. We found that CRP levels were negatively associated with vlPFC activation during implicit regulation of negatively-valenced stimuli, and that cumulative severity of ELS exposure moderated this neuroimmune association. Severity of ELS also significantly moderated the association between CRP levels and FC between the bilateral amygdala and l-vlPFC during implicit emotion regulation: in adolescents who had been exposed to more severe ELS, higher CRP was associated with more negative frontoamygdala FC during implicit regulation of negatively-valenced stimuli. Thus, ELS may disrupt the normative association between the immune system and the neural processes that underlie socioemotional functioning potentially increasing adolescents' risk for maladaptive outcomes.

Correlates and predictors of the severity of suicidal ideation in adolescence: an examination of brain connectomics and psychosocial characteristics

BACKGROUND

Suicidal ideation (SI) typically emerges during adolescence but is challenging to predict. Given the potentially lethal consequences of SI, it is important to identify neurobiological and psychosocial variables explaining the severity of SI in adolescents.

METHODS

In 106 participants (59 female) recruited from the community, we assessed psychosocial characteristics and obtained resting-state fMRI data in early adolescence (baseline: aged 9-13 years). Across 250 brain regions, we assessed local graph theory-based properties of interconnectedness: local efficiency, eigenvector centrality, nodal degree, within-module z-score, and participation coefficient. Four years later (follow-up: ages 13-19 years), participants self-reported their SI severity. We used least absolute shrinkage and selection operator (LASSO) regressions to identify a linear combination of psychosocial and brain-based variables that best explain the severity of SI symptoms at follow-up. Nested-cross-validation yielded model performance statistics for all LASSO models.

RESULTS

A combination of psychosocial and brain-based variables explained subsequent severity of SI (R² = .55); the strongest was internalizing and externalizing symptom severity at follow-up. Follow-up LASSO regressions of psychosocial-only and brain-based-only variables indicated that psychosocial-only variables explained 55% of the variance in SI severity; in contrast, brain-based-only variables performed worse than the null model.

CONCLUSIONS

A linear combination of baseline and follow-up psychosocial variables best explained the severity of SI. Follow-up analyses indicated that graph theory resting-state metrics did not increase the prediction of the severity of SI in adolescents. Attending to internalizing and externalizing symptoms is important in early adolescence; resting-state connectivity properties other than local graph theory metrics might yield a stronger prediction of the severity of SI.

Associations of Irritability With Functional Connectivity of Amygdala and Nucleus Accumbens in Adolescents and Young Adults With ADHD

OBJECTIVE

Irritability is a common characteristic in ADHD. We examined whether dysfunction in neural connections supporting threat and reward processing was related to irritability in adolescents and young adults with ADHD.

METHOD

We used resting-state fMRI to assess connectivity of amygdala and nucleus accumbens seeds in those with ADHD (n = 34) and an age- and gender-matched typically-developing comparison group (n = 34).

RESULTS

In those with ADHD, irritability was associated with atypical functional connectivity of both seed regions. Amygdala seeds showed greater connectivity with right inferior frontal gyrus and caudate/putamen, and less connectivity with precuneus. Nucleus accumbens seeds showed altered connectivity with middle temporal gyrus and precuneus.

CONCLUSION

The irritability-ADHD presentation is associated with atypical functional connectivity of reward and threat processing regions with cognitive control and emotion processing regions. These patterns provide novel evidence for irritability-associated neural underpinnings in adolescents and young adults with ADHD. The findings suggest cognitive and behavioral treatments that address response to reward, including omission of an expected reward and irritability, may be beneficial for ADHD.

Sex-specific vulnerability to depressive symptoms across adolescence and during the COVID-19 pandemic: The role of the cingulum bundle

Background

Females are at higher risk for developing depression during adolescence than are males, particularly during exposure to stressors like the COVID-19 pandemic. Examining structural connections between brain regions involved in executive functioning may advance our understanding of sex biases in stress and depression. Here, we examined the role of the cingulum bundle in differentiating trajectories of depressive symptoms in males and females across adolescence and during the pandemic.

Methods

In a longitudinal study of 214 youth (121 females; ages 9-13 years at baseline), we examined whether fixel-based properties of the cingulum bundle at baseline predict changes in females' and males' severity of depressive symptoms across four timepoints (4-7 years) in adolescence, including during the COVID-19 pandemic. We also tested whether cingulum properties predict self-reported resilience and stress during the pandemic.

Results

Females had lower fiber density and cross-section (FDC) of the cingulum than did males, a neural pattern that predicted greater increases in depressive symptoms, lower resilience, and higher stress during the COVID-19 pandemic. Cingulum morphometry predicted changes in depressive trajectories in females, but not in males; specifically, females with lower FDC had significant increases in symptoms throughout adolescence, whereas females with higher cingulum FDC did not. Conversely, males had low, stable depressive symptoms throughout adolescence and higher resilience and lower stress during the pandemic compared to females. Higher cingulum FDC predicted higher resilience and lower stress in both sexes.

Conclusions

In adults, the cingulum has been implicated in sex differences in stress reactivity. We show that in adolescents, the cingulum reflects sex differences in reports of stress and resilience that might contribute to the increased risk of stress-related mood disorders in females. Adolescent females might benefit from cognitive interventions that strengthen the structural properties of the cingulum and increase their perceived resilience during periods of adversity and disruption.

Early Life Stress and Neurodevelopment in Adolescence: Implications for Risk and Adaptation

An alarming high proportion of youth experience at least one kind of stressor in childhood and/or adolescence. Exposure to early life stress is associated with increased risk for psychopathology, accelerated biological aging, and poor physical health; however, it is important to recognize that not all youth who experience such stress go on to develop difficulties. In fact, resilience, or positive adaptation in the face of adversity, is relatively common. Individual differences in vulnerability or resilience to the effects of early stress may be represented in the brain as specific patterns, profiles, or signatures of neural activation, structure, and connectivity (i.e., neurophenotypes). Whereas neurophenotypes of risk that reflect the deleterious effects of early stress on the developing brain are likely to exacerbate negative outcomes in youth, neurophenotypes of resilience may reduce the risk of experiencing these negative outcomes and instead promote positive functioning. In this chapter we describe our perspective concerning the neurobiological mechanisms and moderators of risk and resilience in adolescence following early life stress and integrate our own work into this framework. We present findings suggesting that exposure to stress in childhood and adolescence is associated with functional and structural alterations in neurobiological systems that are important for social-affective processing and for cognitive control. While some of these neurobiological alterations increase risk for psychopathology, they may also help to limit adolescents' sensitivity to subsequent negative experiences. We also discuss person-centered strategies that we believe can advance our understanding of risk and resilience to early stress in adolescents. Finally, we describe ways in which the field can broaden its focus to include a consideration of other types of environmental factors, such as environmental pollutants, in affecting both risk and resilience to stress-related health difficulties in youth.

Testing a Developmental Model of Positive Parenting, Amygdala–Subgenual Anterior Cingulate Cortex Connectivity, and Depressive Symptoms in Adolescents Before and During the COVID-19 Pandemic

Background

Neurobiological measures may inform our understanding of individual differences in adolescents’ general risk for and resilience to depressive symptoms, including during the COVID-19 pandemic. We tested a developmental model linking variation in amygdala–subgenual anterior cingulate cortex (sgACC) resting-state connectivity to perceived parenting experiences earlier in adolescence, to concurrent depressive symptoms before the pandemic, and to subsequent depressive symptoms during the pandemic.

Methods

We used data from a longitudinal study that included three waves (N = 214 adolescents; ages 9–15 years at time 1 [T1], 11–17 years at T2, and 12–19 years during the pandemic at T3). We assessed positive parenting (warm and supportive) (T1), depressive symptoms (T1 to T3), and functional connectivity between the sgACC and basolateral (BLA) and centromedial amygdala (T1 and T2). We modeled associations among earlier positive parenting, amygdala–sgACC connectivity, and depressive symptoms before and during the pandemic.

Results

Less positive parenting at T1 was associated prospectively with stronger BLA–sgACC connectivity at T2 (β = −0.22) over and above the effect of BLA–sgACC connectivity at T1. Stronger BLA–sgACC connectivity, in turn, was associated with heightened depressive symptoms, both before the pandemic (r = 0.21) and during the pandemic (β = 0.19; independent of the effect of pre-pandemic symptoms).

Conclusions

Adolescents who experience less positive parenting may develop a pattern of BLA–sgACC connectivity that increases their risk for mental health problems. BLA–sgACC connectivity may be associated with depressive symptoms in general, including during periods of heightened risk for adolescents, such as the pandemic.

Neural connectivity biotypes: associations with internalizing problems throughout adolescence

BACKGROUND

Neurophysiological patterns may distinguish which youth are at risk for the well-documented increase in internalizing symptoms during adolescence. Adolescents with internalizing problems exhibit altered resting-state functional connectivity (RSFC) of brain regions involved in socio-affective processing. Whether connectivity-based biotypes differentiate adolescents' levels of internalizing problems remains unknown.

METHOD

Sixty-eight adolescents (37 females) reported on their internalizing problems at ages 14, 16, and 18 years. A resting-state functional neuroimaging scan was collected at age 16. Time-series data of 15 internalizing-relevant brain regions were entered into the Subgroup-Group Iterative Multi-Model Estimation program to identify subgroups based on RSFC maps. Associations between internalizing problems and connectivity-based biotypes were tested with regression analyses.

RESULTS

Two connectivity-based biotypes were found: a Diffusely-connected biotype (N = 46), with long-range fronto-parietal paths, and a Hyper-connected biotype (N = 22), with paths between subcortical and medial frontal areas (e.g. affective and default-mode network regions). Higher levels of past (age 14) internalizing problems predicted a greater likelihood of belonging to the Hyper-connected biotype at age 16. The Hyper-connected biotype showed higher levels of concurrent problems (age 16) and future (age 18) internalizing problems.

CONCLUSIONS

Differential patterns of RSFC among socio-affective brain regions were predicted by earlier internalizing problems and predicted future internalizing problems in adolescence. Measuring connectivity-based biotypes in adolescence may offer insight into which youth face an elevated risk for internalizing disorders during this critical developmental period.

Heart rate variability moderates the effects of COVID-19-related stress and family adversity on emotional problems in adolescents: Testing models of differential susceptibility and diathesis stress

The COVID-19 pandemic is a unique period of stress, uncertainty, and adversity that will have significant implications for adolescent mental health. Nevertheless, stress and adversity related to COVID-19 may be more consequential for some adolescents' mental health than for others. We examined whether heart rate variability (HRV) indicated differential susceptibility to mental health difficulties associated with COVID-19 stress and COVID-19 family adversity. Approximately 4 years prior to the pandemic, we assessed resting HRV and HRV reactivity to a well-validated stress paradigm in 87 adolescents. During the pandemic, these adolescents (ages 13-19) reported on their health-related stress and concerns about COVID-19, family adversity related to COVID-19, and their recent emotional problems. The association between COVID-19 stress and emotional problems was significantly stronger for adolescents who previously exhibited higher resting HRV or higher HRV reactivity. For adolescents who exhibited lower resting HRV or HRV augmentation, COVID-19 stress was not associated with emotional problems. Conversely, lower resting HRV indicated vulnerability to the effect of COVID-19 family adversity on emotional problems. Different patterns of parasympathetic functioning may reflect differential susceptibility to the effects of COVID-19 stress versus vulnerability to the effects of COVID-19 family adversity on mental health during the pandemic.

Neural responses to implicit forms of peer influence in young adults

Young adults are acutely sensitive to peer influences. Differences have been found in neural sensitivity to explicit peer influences, such as seeing peer ratings on social media. The present study aimed to identify patterns of neural sensitivity to implicit peer influences, which involve more subtle cues that shape preferences and behaviors. Participants were 43 young adults (M_Age = 19.2 years; 24 males) who underwent functional magnetic resonance imaging while completing a task used to assess neural responses to implicitly "socially tagged" symbols (previously judged by peers as liked vs. not liked, thus differing in apparent popularity) vs. novel symbols that carried no social meaning (not judged by peers). Results indicated greater activity in brain regions involved in salience detection (e.g., anterior cingulate cortex) and reward processing (e.g., caudate) to socially tagged vs. novel symbols, and particularly to unpopular symbols. Greater self-reported susceptibility to peer influence was related to more activity in the insula and caudate when viewing socially tagged vs. novel symbols. These results suggest that the brain is sensitive to even subtle cues varying in level of peer endorsement and neural sensitivity differed by the tendency to conform to peers' behaviors particularly in regions implicated in social motivation.

Greater age-related changes in white matter morphometry following early life stress: Associations with internalizing problems in adolescence

Early life stress (ELS) is associated with increased risk for internalizing disorders and variations in gray matter development. It is unclear, however, whether ELS affects normative age-related changes in white matter (WM) morphology, and if such maturational differences are associated with risk for internalizing psychopathology. We conducted comprehensive interviews in a cross-sectional sample of young adolescents (N = 156; 89 F; Ages 9-14) to assess lifetime exposure to stress and objective cumulative ELS severity. We used diffusion-weighted imaging to measure WM fixel-based morphometry and tested the effects of age and ELS on WM fiber density and cross-section (FDC), and associations between WM FDC and internalizing problems. Age was positively associated with FDC in all WM tracts; greater ELS severity was related to stronger age-WM associations in several association tracts connecting the frontal lobes with limbic, parietal, and occipital regions, including bilateral superior and inferior longitudinal and uncinate fasciculi (UF). Among older adolescents with greater ELS severity, a higher UF FDC was associated with fewer internalizing problems. Greater ELS severity predicted more mature WM morphometry in tracts implicated in emotion regulation and cognitive processing. More phenotypically mature UF WM may be adaptive against internalizing psychopathology in adolescents exposed to ELS.

Early Life Stress Predicts Depressive Symptoms in Adolescents During the COVID-19 Pandemic: The Mediating Role of Perceived Stress

BACKGROUND

Exposure to early life stress (ELS) is alarmingly prevalent and has been linked to the high rates of depression documented in adolescence. Researchers have theorized that ELS may increase adolescents' vulnerability or reactivity to the effects of subsequent stressors, placing them at higher risk for developing symptoms of depression.

METHODS

We tested this formulation in a longitudinal study by assessing levels of stress and depression during the COVID-19 pandemic in a sample of adolescents from the San Francisco Bay Area (N = 109; 43 male; ages 13-20 years) who had been characterized 3-7 years earlier (M = 5.06, SD = 0.86 years) with respect to exposure to ELS and symptoms of depression.

RESULTS

As expected, severity of ELS predicted levels of depressive symptoms during the pandemic [r(107) = 0.26, p = 0.006], which were higher in females than in males [t(107) = -3.56, p < 0.001]. Importantly, the association between ELS and depression was mediated by adolescents' reported levels of stress, even after controlling for demographic variables.

CONCLUSIONS

These findings underscore the importance of monitoring the mental health of vulnerable children and adolescents during this pandemic and targeting perceived stress in high-risk youth.

Research Review: Brain network connectivity and the heterogeneity of depression in adolescence - a precision mental health perspective

BACKGROUND

Adolescence is a period of high risk for the onset of depression, characterized by variability in symptoms, severity, and course. During adolescence, the neurocircuitry implicated in depression continues to mature, suggesting that it is an important period for intervention. Reflecting the recent emergence of 'precision mental health' - a person-centered approach to identifying, preventing, and treating psychopathology - researchers have begun to document associations between heterogeneity in features of depression and individual differences in brain circuitry, most frequently in resting-state functional connectivity (RSFC).

METHODS

In this review, we present emerging work examining pre- and post-treatment measures of network connectivity in depressed adolescents; these studies reveal potential intervention-specific neural markers of treatment efficacy. We also review findings from studies examining associations between network connectivity and both types of depressive symptoms and response to treatment in adults, and indicate how this work can be extended to depressed adolescents. Finally, we offer recommendations for research that we believe will advance the science of precision mental health of adolescence.

RESULTS

Nascent studies suggest that linking RSFC-based pathophysiological variation with effects of different types of treatment and changes in mood following specific interventions will strengthen predictions of prognosis and treatment response. Studies with larger sample sizes and direct comparisons of treatments are required to determine whether RSFC patterns are reliable neuromarkers of treatment response for depressed adolescents. Although we are not yet at the point of using RSFC to guide clinical decision-making, findings from research examining the stability and reliability of RSFC point to a favorable future for network-based clinical phenotyping.

CONCLUSIONS

Delineating the correspondence between specific clinical characteristics of depression (e.g., symptoms, severity, and treatment response) and patterns of network-based connectivity will facilitate the development of more tailored and effective approaches to the assessment, prevention, and treatment of depression in adolescents.

Sex differences in pubertal associations with fronto-accumbal white matter morphometry: Implications for understanding sensitivity to reward and punishment

Researchers have reported sex-differentiated maturation of white matter (WM) during puberty. It is not clear, however, whether such distinctions contribute to documented sex differences in sensitivity to reward and punishment during adolescence. Given the role of the orbitofrontal cortex (OFC) and nucleus accumbens (NAcc) in reward and punishment-related behaviors, we tested in a cross-sectional study whether males and females (N = 156, 89 females; ages 9-14 years) differ in the association between pubertal stage and fixel-based morphometry of WM fibers connecting the OFC and NAcc (i.e., the fronto-accumbal tract). Further, we examined whether males and females differ in associations between fronto-accumbal WM measures and self-reported sensitivity to reward and punishment. Pubertal stage was positively associated with fronto-accumbal fiber density and cross-section (FDC) in males, but not in females. Consistent with previous reports, males reported higher reward sensitivity than did females, although fronto-accumbal combined FDC was not related to reward sensitivity in either sex. Meanwhile, only males showed a negative association between fronto-accumbal tract FDC and sensitivity to punishment. Follow-up analyses revealed that fiber cross-section, but not density, was related to pubertal stage and punishment sensitivity in males, as well as to reward sensitivity in all participants. Our findings suggest there are sex differences in puberty-related maturation of the fronto-accumbal tract, and this tract is related to lower punishment sensitivity in adolescent males compared to females.

Girls' brain structural connectivity in late adolescence relates to history of depression symptoms

BACKGROUND

Girls' depressive symptoms typically increase in adolescence, with individual differences in course and severity being key risk factors for impaired emotional functioning in young adulthood. Given the continued brain white matter (WM) maturation that occurs in adolescence, the present study tested whether structural connectivity patterns in late adolescence are associated with variation in the course of depression symptom severity throughout adolescence.

METHOD

Participants were girls (N = 115) enrolled in a multiyear prospective cohort study of risk for depression. Initial depression severity (intercept) at age 10 and change in severity (linear slope) across ages 10-19 were examined in relation to WM tractography collected at age 19. Network-based statistic analyses were used to identify clusters showing variation in structural connectivity in association with depressive symptom intercept, slope, and their interaction.

RESULTS

Higher initial depressive severity and steeper positive slope (separately) were associated with greater structural connectivity between temporal, subcortical socioaffective, and occipital regions. Intercept showed more connectivity associations than slope. The interaction effect indicated that higher initial symptom severity and a steeper negative slope (i.e., alleviating symptoms) were related to greater connectivity between cognitive control regions. Moderately severe symptoms that worsened over time were followed by greater connectivity between self-referential and cognitive regions (e.g., posterior cingulate and frontal gyrus).

CONCLUSIONS

Higher depressive symptom severity in early adolescence and increasing symptom severity over time may forecast structural connectivity differences in late adolescence, particularly in pathways involving cognitive and emotion-processing regions. Understanding how clinical course relates to neurobiological correlates may inform new treatment approaches to adolescent depression.

Higher Executive Control Network Coherence Buffers Against Puberty-Related Increases in Internalizing Symptoms During the COVID-19 Pandemic

BACKGROUND

Early pubertal maturation has been posited to be a biopsychosocial risk factor for the onset of internalizing psychopathology in adolescence; further, early-maturing youths exhibit heightened reactivity to stressful events. School closures and enforced social distancing, as well as health and financial uncertainties, during the COVID-19 pandemic are expected to adversely affect mental health in youths, particularly adolescents who are already at risk for experiencing emotional difficulties. The executive control network (ECN) supports cognitive processes required to successfully navigate novel challenges and regulate emotions in stressful contexts.

METHODS

We examined whether functional coherence of the ECN, measured using resting-state functional magnetic resonance imaging 5 years before the pandemic (T1), is a neurobiological marker of resilience to increases in the severity of internalizing symptoms during COVID-19 in adolescents who were in more advanced stages of puberty at T1 relative to their same-age peers (N = 85, 49 female).

RESULTS

On average, participants reported an increase in symptoms from the 3 months before pandemic to the 2 most recent weeks during the pandemic. We found that early-maturing youths exhibited greater increases in internalizing symptoms during the pandemic if their ECN coherence was low; in contrast, relative pubertal stage was not associated with changes in internalizing symptoms in adolescents with higher ECN coherence at T1.

CONCLUSIONS

These findings highlight the role of the functional architecture of the brain that supports executive functioning in protecting against risk factors that may exacerbate symptoms of internalizing psychopathology during periods of stress and uncertainty.

Support, information, and integration of genetics for children with congenital lower limb deficiencies in British Columbia, Canada

Objectives

Children and families affected by congenital limb deficiencies (CLD) require a unique level of emotional support from diagnosis through to adolescence. The following study aims to collect data on Canadian paediatric patients affected by a CLD followed at BC Children's Hospital (BCCH), Department of Orthopaedics.

Methods

Parents of children with a CLD were asked to complete a written questionnaire examining their experiences. Qualitative and quantitative data were collected concerning parent satisfaction with patient referrals, emotional support, and knowledge of their child's diagnosis.

Results

Twenty-five completed questionnaires were returned. Fifty per cent of the parents reported they were either very satisfied, or satisfied, with the emotional support provided by health care providers (HCPs). Twenty-five per cent of the parents were unsatisfied with the emotional support received by HCPs. Forty-eight per cent of the parents could not recall the specific name of their child's diagnosis; 20% of the parents reported their child did not have diagnosis. All the patients in our study had received a clinical diagnosis. Twenty-eight per cent of the parents in this study were also seen in medical genetics.

Conclusions

Families require additional resources for emotional support, peer support, and referrals to support organizations. Gaps in parent knowledge regarding their child's CLD suggest the need for formalized communication strategies for HCPs. Furthermore, patients with CLDs and their families may benefit from improved communication between orthopaedic and medical genetic services at the time of diagnosis. Integration of genetic counsellors may improve emotional supports and education for families with regards to testing and reproductive planning.

Modulation of reward-related neural activation on sensation seeking across development

Sensation seeking is a personality construct associated with an increased propensity for engaging in risk-taking. Associations with deleterious outcomes ranging from mental health impairments to increased mortality rates highlight important public health concerns related to this construct. Although some have suggested that increased neural responsivity to reward within the ventral striatum (e.g., nucleus accumbens) may drive sensation seeking behaviors, few studies have examined the neural mechanisms associated with stable individual differences in sensation seeking across development. To address this issue, the current study used functional magnetic resonance imaging to examine the association between neural responding to reward and stable patterns of sensation seeking across a three-year follow-up period among healthy adolescents and young adults (N = 139). Results indicated that during early adolescence (~ages 10-12), increased reactivity to reward within the nucleus accumbens (NAcc) was associated with lower levels of sensation seeking across a three-year follow-up. In middle adolescence (~ages 12-16), there was no evidence of a relationship between NAcc reactivity and sensation seeking. However, during the transition from late adolescence into adulthood (~ages 17-25), heightened reward-related reactivity in the NAcc was linked to increased sensation seeking. Findings suggest that the neural mechanisms underlying individual differences in trait-like levels of sensation seeking change from early to late adolescence.

An integrative model of the maturation of cognitive control

Brains systems undergo unique and specific dynamic changes at the cellular, circuit, and systems level that underlie the transition to adult-level cognitive control. We integrate literature from these different levels of analyses to propose a novel model of the brain basis of the development of cognitive control. The ability to consistently exert cognitive control improves into adulthood as the flexible integration of component processes, including inhibitory control, performance monitoring, and working memory, increases. Unique maturational changes in brain structure, supported by interactions between dopaminergic and GABAergic systems, contribute to enhanced network synchronization and an improved signal-to-noise ratio. In turn, these factors facilitate the specialization and strengthening of connectivity in networks supporting the transition to adult levels of cognitive control. This model provides a novel understanding of the adolescent period as an adaptive period of heightened experience-seeking necessary for the specialization of brain systems supporting cognitive control.

Wavelength conversion in Er(3+) doped chalcogenide fibers for optical gas sensors

We report for the first time the conversion of incoherent infrared light around 4.4µm into a near-infrared signal at 810nm in erbium-doped GaGeSbS fibers and bulk glass samples. This energy conversion is made possible by pumping erbium doped chalcogenide samples at 982 nm and simultaneously exciting them with a 4.4µm infrared signal. This result paves the way for the development of an "all-optical" gas sensor able to detect various gas traces using a remote detection based on commercial silica fibers.

PATIENTS AT HIGH RISK FOR UPPER TRACT UROTHELIAL CANCER: EVALUATION OF HYDRONEPHROSIS USING HIGH RESOLUTION MAGNETIC RESONANCE UROGRAPHY

PURPOSE

We assessed the potential of magnetic resonance urography (MRU) in the evaluation of hydronephrosis not explained by standard investigation in patients at high risk for upper tract urothelial cancer.

MATERIALS AND METHODS

A total of 23 consecutive patients in a specialist urological unit with unexplained hydronephrosis prospectively underwent MRU which comprised overview heavily T2-weighted MR urographic images followed by focused high resolution turbo spin echo T2-weighted sequences obtained in an axial and coronal oblique plane through the level of urinary obstruction. All were at high risk for urothelial cancer and had either contraindications to or problems with standard investigations including poor contrast excretion due to obstruction or renal failure, failed ureteral cannulation or contrast allergy. Clinical events and imaging followup, subsequent endoscopic/surgical findings and histopathology validated MR findings.

RESULTS

In 23 patients with a high clinical suspicion of upper tract transitional cell tumors (TCC), 8 ureteral and 5 renal pelvic TCCs (2 bilateral) were diagnosed by MR, and confirmed histologically. In a further 5 patients benign causes for the hydronephrosis were found. No intrinsic or extrinsic pathology was demonstrable in 5 patients whose imaging findings were stable during 1 year of followup.

CONCLUSIONS

MRU is a valuable noninvasive investigation for evaluating hydronephrosis in this group of patients with suspected urothelial cancer in which routine investigation had failed to provide clinically important information. Focused high resolution T2-weighted images were reliable in the diagnosis of ureteral and renal pelvic TCCs, and were valuable in excluding these and other mass lesions as the cause of hydronephrosis.

Ureteric Complications of Renal Transplantation: The Impact of the Double J Stent and the Anterior Extravesical Ureteroneocystostomy

The urological complications of renal transplantation are well documented. In 1990, our experience of 507 consecutive renal transplants using the Leadbetter-Politano technique, which was unsplinted in the vast majority of patients, had a ureteric complication rate of 7.7%. Here, we report the long-term incidence and management of our ureteric complications in 1186 consecutive renal transplants done over the following 11 years using an extravesical onlay stented ureteroneocystostomy. We report a considerable reduction in the urological complications of renal transplantation to 3.8%. Furthermore, we were able to use percutaneous radiological techniques to salvage the majority (84.7%) of ureteric complications. Recourse to surgery was required rarely but enabled salvage of all treatment failures.

Evaluation of Painful Hydronephrosis in Pregnancy:: Magnetic Resonance Urographic Patterns in Physiological Dilatation Versus Calculous Obstruction

PURPOSE

We evaluated magnetic resonance urography (MRU) appearances in symptomatic hydronephrosis in pregnancy and compared urographic patterns in physiological and calculous disease.

MATERIALS AND METHODS

A total of 24 consecutive pregnant women with symptomatic hydronephrosis underwent MRU, comprising an overview fast T2-weighted examination of the abdomen and pelvis, and thick slab, heavily T2-weighted MRU images, followed by focused, high resolution T2-weighted sequences obtained in an axial and coronal oblique plane through the level of ureteral caliber change.

RESULTS

Of these 24 pregnant women 15 were found to have physiological hydronephrosis, 7 had calculous disease and 2 had preexisting urinary anomalies. MRU findings in physiological hydronephrosis cases were extrinsic compression of the middle third of the ureter, no filling defect and a collapsed ureter below it. Obstruction by ureteral calculi was seen at points of ureteral narrowing in the ureter, that is at the vesicoureteral junction in 2 cases, in the compressed mid ureter in 3 and at the pelviureteral junction in 1. Nonobstructive renal calculi were seen in another patient. Calculi presented throughout pregnancy but physiological hydronephrosis presented only in the late second and third trimesters. With distal calculi the MRU appearance was the double kink sign with constriction at the pelvic brim and the vesicoureteral junction with a standing column of urine in the pelvic ureter. There was renal edema and perirenal extravasation. Small calculi were only identified using high resolution T2-weighted magnetic resonance imaging.

CONCLUSIONS

MRU is a valuable and well tolerated investigation for evaluating painful hydronephrosis in pregnancy. There are characteristic and differing urographic appearances in physiological and calculous obstruction.

A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire

OBJECTIVES

To study the morbidity of radical cystectomy and radical radiotherapy in the treatment of patients with invasive carcinoma of the bladder and to report the long-term survival following these treatments.

PATIENT AND METHODS

398 patients with invasive carcinoma of the bladder treated between 1993 and 1996 in the Yorkshire region were studied. Of 398 patients studied, 302 patients received radical radiotherapy and 96 underwent radical cystectomy. A retrospective review of patients' case notes was performed to construct a highly detailed database. Crude estimates of survival differences were derived using Kaplan-Meier methods. Log-rank tests (or, where appropriate, Wilcoxon tests) were used to test for the equality of these survivor functions. These functions were produced as all-cause survival. The proportional hazards regression modelling was used to assess the impact of definitive treatment on survival. A backwards-stepwise approach was used to derive a final predictive model of survival, with likelihood ratio tests to assess the statistical significance of variables to be included in the model.

RESULTS

The patients undergoing radiotherapy were significantly older (mean age: 71 years versus 66 years), but no difference was identified in the distribution of American Society of Anaesthesiologists (ASA) grades in the two treatment groups. The stage distribution of cases in the treatment groups was not significantly different. Significant treatment delays were observed in both treatment groups. The median time from being seen in the clinic to transurethral resection of bladder tumour (TURBT) and subsequent radical treatment (cystectomy or radiotherapy) was 4.3 and 9 weeks, respectively. Age was the most significant independent factor accounting for treatment delays (p < 0.001). The 30-day and 3-month treatment-associated mortality for radical cystectomy and radiotherapy was 3.1% and 8.3% and 0.3% and 1.65%. Of the patients who received radiotherapy, 57 (18.8%) were subsequently subjected to a salvage cystectomy. For these 57 patients, 30-day and 3-month mortality after the salvage cystectomy were 8.8% and 15.7%. Gastrointestinal complications were the major source of early morbidity after primary and salvage cystectomy. Bowel leakage occurred in 3% following radical and 8.7% after salvage cystectomy. Bowel complications (leakage and obstruction) were the major cause of death following salvage cystectomy. No specific cause was predominant in those undergoing radical cystectomy with intestinal anastomotic leakage and urinary leakage accounting for one death each. Exacerbation of co-morbid conditions accounted for the remaining causes of mortality. Urinary leakage occurred in 4% following both forms of cystectomy. Recurrent pyelonephritis and intestinal obstruction were responsible for the majority of complications in the follow-up period. Bladder and gastrointestinal complications accounted for the majority of complications following radical radiotherapy. Some degree of irritative bladder and rectal were noted commonly. Severe bladder problems, which rendered the bladder non-functional or required surgical correction, occurred in 6.3% of patients. 2.3% of patients underwent surgery for bowel obstruction related to radiotherapy induced bowel strictures. Following radiotherapy, 43.6% of patients had a recurrence in the bladder at varying intervals post-treatment. Of these, 40% had > or =T2 disease. The 5-year survival following radiotherapy (with or without salvage cystectomy) was 37.4% while 36.5% of patients were alive 5 years after radical cystectomy. There was no statistically significant difference in the overall 5-year survival figures between the two primary treatments. Tumour stage, ASA grade and sex were the only independent predictors of 5-year survival on multivariate analysis.

CONCLUSIONS

This retrospective regional study shows that there is no significant difference in the 5-year survival of patients with invasive bladder cancer treated with either radical radiotherapy or radical cystectomy. All forms of radical treatment for bladder cancer are associated with a significant treatment-associated morbidity and mortality. Gastrointestinal complications were responsible for the majority of complications. The treatment-associated mortality at 3 months was two- or three-fold higher than the 30-day mortality; emphasising its importance as an indicator of the true risks of cystectomy. The clinical T stage, the sex and the ASA grade of the patient were the only independent predictors of survival. The data in this series suggests that radical radiotherapy and radical cystectomy should be both considered as valid primary treatment options for the management of invasive bladder cancer.

MALT-type primary lymphoma of the urinary bladder: clinicopathological study of 2 cases and review of the literature

Primary lymphoma of the bladder is a rare non-epithelial bladder tumour. It is usually non-Hodgkin's lymphoma with mucosa-associated lymphoid tissue (MALT) lymphoma being its predominant subtype. Most of the literature has been limited to individual sporadic case reports. We present 2 cases of the MALT-type primary lymphoma of the urinary bladder which were treated in our unit. Both patients were females with a history of recurrent urinary tract infections. They were treated successfully with chemotherapy alone. We also present a review of the literature emphasising the clinical presentation, the morphological and immunophenotypic features and the various treatment modalities of this rarely seen bladder pathology.

Evaluation of the clinical value of urinary NMP22 as a marker in the screening and surveillance of transitional cell carcinoma of the urinary bladder

PURPOSE

To prospectively evaluate the clinical role of urinary NMP22 as a marker for transitional cell carcinoma of the urinary bladder in screening and surveillance settings.

PATIENTS AND METHODS

Single voided specimens were obtained from 211 consecutive patients who presented for flexible cystoscopy. Of these, 96 patients presented with haematuria or irritative symptoms (screening), the remaining 115 were patients with known transitional cell carcinoma on follow-up (surveillance). The urine sample was used for urine microscopy, cytology and for measuring NMP22 levels.

RESULTS

Bladder tumours were found in 16 of 96 (16.6%) patients in the screening group and 17 of 115 (15.6%) patients on surveillance. The NMP22 levels were significantly lower in patients with lower stage (Ta vs. T1-3), low grade (G1, G2 vs. G3, CIS) and papillary morphology. The optimum threshold for NMP22 obtained from the ROC curve was 4.75 U/ml, providing a sensitivity, specificity, positive predictive value and negative predictive value of 42.4, 85, 38.5 and 88.6%, respectively. Sensitivity and specificity were better in patients being screened than in those on surveillance. In both groups, urinary NMP22 had similar diagnostic characteristics as urinary cytology.

CONCLUSIONS

Urinary NMP22 levels are significantly higher in patients with bladder tumour than in those negative for tumours, and test predictability improves with increasing stage and grade. The overall sensitivity for urinary NMP22 is similar to, but not superior to urine cytology. Our study suggests that the clinical role of urinary NMP22 as a diagnostic marker can be at best supportive only.

Is it necessary to perform urine cytology in screening patients with haematuria?

All patients with gross haematuria and those older than 50 years with microscopic haematuria need investigations to rule out the presence of a urological malignancy.

OBJECTIVE

To study the role of urine cytology in the evaluation of patients with haematuria.

METHODS

Two hundred and eighty-five patients were evaluated. All patients underwent evaluation including urine cytology, flexible cystoscopy, ultrasonography and/or IVU.

RESULTS

The mean age of the patients was 62.4 years. Sixty-five percent had gross and 35% microscopic haematuria. Fifty-five tumours were discovered (19.2%); of these 48 were transitional cell carcinomas, 3 renal cell carcinomas and 3 carcinomas of the prostate. Thirty-seven urinary cytologies were abnormal. The overall sensitivity of urinary cytology was 42.4% and specificity 94.3%. Of 18 patients with positive cytology, all were found to have transitional cell carcinomas on cystoscopy or imaging. Of 19 patients with suspicious cytologies, only 6 were found to have tumours. The remaining 13 patients had no evidence of tumour on combined upper tract imaging (IVU and ultrasound) or on rigid cystoscopy and bladder biopsy. Whilst all the other investigation modalities contributed to diagnoses (and/or exclusion of tumours), no additional tumours were discovered solely by urinary cytology. A moderate cost saving could be made without compromising diagnostic accuracy.

CONCLUSION

Our study suggests that performing routine urine cytology is not relevant in the investigation of patients with haematuria, its role is at best supportive.

Corporal plication for penile curvature caused by Peyronie's disease: the patients' perspective

OBJECTIVE

To determine the acceptability by patients of corporal plication for Peyronie's disease.

PATIENTS AND METHODS

A postal questionnaire was sent to 69 patients who had undergone corporal plication for Peyronie's disease between 1992 and 1999, to ascertain the subjective outcome and acceptance by the patients and their sexual partners of the results of the procedure. Of the 65 patients who were still alive, 44 (68%) returned the questionnaire.

RESULTS

The mean (range) follow-up was 4.1 (0.5-7.25) years and the mean age of the patients 54.6 (32-80) years. Of the 44 patients responding, 24 (55%) were sexually active; after surgery, 16 (36%) had significant impairment of erections, seven (16%) continued to have significant penile discomfort and 15 (34%) could feel nodules at the suture site. Twenty-five (57%) patients reported a mild and six (14%) a severe persistent penile deformity; 40 (90%) reported having a shorter penis, of whom 22 (55%) thought it significant. Overall, 14 (32%) reported 'numbness' of the glans penis. Only 23 (52%) of the patients would recommend the surgery, with 25 (57%) reporting a deterioration in their overall quality of life. Of the partners of the evaluable patients, 38 (86%) responded, and a significant deterioration in sexual performance was reported by 19 (35%).

CONCLUSIONS

Overall, the long-term results of corporal plication appear to be disappointing. These poor results could be related to a current lack of understanding of the natural history and progression of the disease, to case selection, or to the surgery. We intend to use these results to counsel our patients before such surgery and inform them of the possible outcome in the long term.

Assessment of voiding outcome, sexual function and quality of life two years following KTP/YAG hybrid laser prostatectomy

OBJECTIVE

To assess the long-term outcome of patients undergoing KTP/YAG hybrid laser treatment for bladder outlet obstruction due to benign prostatic enlargement, in terms of symptomatic relief, complications, sexual function, patient satisfaction and acceptance of procedure.

PATIENTS AND METHODS

The study recruited 148 patients prospectively. The hybrid laser treatment involved performing an initial bladder neck incision using KTP laser at 34 W followed by 4/6 point coagulation using NdYAG laser at 60 W. Patients were followed up till 2 years and assessed using uroflowmetry, International Prostate Symptom Score (IPSS), Patient Satisfaction Score (PSS), BPH impact index (BII) and the Danish Prostate Symptom Score (DAN-PSS) sexual function questionnaire.

RESULTS

137 patients were followed up for 2 years. There was a significant improvement in the maximum flow rate, IPSS and Quality of Life Scale (QLS). The mean BII (2.9) and the mean PSS (1.9) were low suggesting overall satisfaction with the procedure. The complications included urethral stricture (0.73%), bladder neck obstruction (2.15%) and retreatment (3.6%). 79.4% had a significant decrease in the ejaculate and 32.8% had a significant change in the strength of erections. On comparing the two groups (sexual function affected vs. not affected), the age, BII, IPSS and PSS were significantly higher (p < 0.05) in the group of patients that were affected.

CONCLUSIONS

Following KTP/YAG hybrid laser prostatectomy the outcome for voiding is good and durable for up to 2 years. The patient satisfaction level following the procedure is high and the procedure well accepted. However, significant interference with sexual function occurs, which appears to be occurring in tandem with a poor voiding outcome.

Total genitourinary reconstruction in adult female epispadias: a report of 2 cases and literature review

Female incontinent episadias is a very rare congenital anomaly presenting in childhood. We report 2 cases of adults presenting with this anomaly. These were treated by total genitourinary reconstruction in a single stage using a combined perineal abdominal approach, with satisfactory results. We recommend this technique as the procedure of choice in adults presenting with this rare anomaly.

Management of obliterative posttraumatic posterior urethral strictures after failed initial urethroplasty

PURPOSE

We evaluate the problems encountered during surgery and assess the results of different endoscopic and open surgical methods following failed urethroplasty for posttraumatic posterior urethral stricture.

MATERIALS AND METHODS

Since 1992 we have treated 23 patients in whom urethroplasty for posterior urethral strictures failed. Of these patients, 3 had undergone 2 previous repairs and 6 had additional complicating factors, such as fistula, periurethral cavity and false passage. End-to-end anastomosis was done in 14 patients via a transperineal (7) or transpubic (7) approach. In 1 patient substitution urethroplasty using a radial artery based forearm free flap was performed. In 3 patients a 2-stage urethroplasty was done, 4 underwent core-through optical internal urethrotomy and 1 underwent endoscopic marsupialization of a false passage.

RESULTS

At 1 to 5-year followup 3 of the 23 patients had restenoses (13%), including 2 in whom previous treatment failed. The remaining 87% of the patients void well and are continent, and there is no worsening of the preexisting potency status.

CONCLUSIONS

Previous failed urethral stricture repair complicates management due to fibrosis, impaired vascularity and limited urethra available for mobilization. Recurrent strictures less than 1.5 cm. can be managed successfully with core-through internal urethrotomy. End-to-end anastomosis is possible in the majority with generous use of inferior pubectomy or the transpubic approach with certain modifications. When residual inflammation or long strictures are present a 2-stage procedure is a safer option. Overall, reoperation can offer a successful outcome for the majority of these complex strictures.

Free-flap urethroplasty for a complex, long-segment stricture of the bulbomembranous urethra

Long strictures of the bulbomembranous urethra are a challenge of modern urology, with no absolutely reliable technique for a favorable outcome. The authors describe a technique of urethroplasty using the radial forearm free flap, in a patient suffering from posttraumatic stricture, with excellent results.

Symptomatic adrenal myelolipoma. Clinicopathological analysis of 7 cases and brief review of the literature

Seven cases of adrenal myelolipoma comprising 5.8% of total adrenal tumors are described with a male-to-female ratio of 1.3:1. Five were symptomatic, of which 4 had a palpable abdominal mass, 2 cases detected incidentally were associated with carcinoma of the uterine cervix and renal cell carcinoma, respectively. The average age and duration of symptoms at presentation were 56 years (range 38-70 years) and 3.16 months (range 1-9 months). A CT scan was done in all cases, of which 5 showed a nonenhancing mass lesion with fat density diagnosed as adrenal myelolipoma. However, in 1 case radiological diagnosis of liposarcoma was maintained because of the huge size of the lesion whereas in another case the lesion was missed because of associated renal cell carcinoma. Interestingly the right adrenal was involved in all cases and the weight varied from 7 to 2,000 g. No recurrence was noted in the follow-up period (ranging from 3 months to 10 years).

Metastatic carcinoma involving the testes

Metastatic carcinoma to testis is an extremely rare but interesting phenomenon. Over a period of nineteen years 300 testicular tumors were diagnosed in our department, and of which 10 were metastatic carcinoma from other sites. Four of these patients (40%) presented as testicular lump of which two were already diagnosed cases of squamous cell carcinoma larynx and adenocarcinoma of lung, and two had occult primary in the kidney and colon. However six (60%) were detected incidentally in the orchiectomy done as a part of hormonal therapy for carcinoma prostate.