Variation in the incidence of uterine leiomyoma among premenopausal women by age and race

OBJECTIVE

To quantify the incidence of uterine leiomyoma confirmed by hysterectomy, ultrasound, or pelvic examination according to age and race among premenopausal women.

METHODS

From September 1989 through May 1993, 95,061 premenopausal nurses age 25-44 with intact uteri and no history of uterine leiomyoma were followed to determine incidence rates of uterine leiomyoma. The self-reported diagnosis was confirmed in 93% of the medical records obtained for a sample of cases. Using pooled logistic regression, we estimated relative risks (RRs) of uterine leiomyoma according to race and examined whether adjustment for other potential risk factors could explain the variation in the race-specific rates.

RESULTS

During 327,065 woman-years, 4181 new cases of uterine leiomyoma were reported. The incidence rates increased with age, and the age-standardized rates of ultrasound- or hysterectomy-confirmed diagnoses per 1000 woman-years were 8.9 among white women and 30.6 among black women. After further adjustment for marital status, body mass index, age at first birth, years since last birth, history of infertility, age at first oral contraceptive use, and current alcohol consumption, the rates among black women were significantly greater for diagnoses confirmed by ultrasound or hysterectomy (RR 3.25; 95% confidence interval [CI] 2.71, 3.88) and by hysterectomy (RR 1.82; 95% CI 1.17, 2.82) compared with rates among white women. We observed similar RRs when the cohort was restricted to participants who reported undergoing a screening physical examination within the 2 years before baseline.

CONCLUSION

A higher prevalence of known risk factors did not explain the excess rate of uterine leiomyoma among premenopausal black women.

Mortality from second tumors among long-term survivors of retinoblastoma

BACKGROUND

Children diagnosed with retinoblastoma, a rare cancer of the eye, tend to develop and die of second primary cancers in childhood and adolescence, but few investigations have followed patients into adulthood. Retinoblastoma is frequently caused by inherited mutations of the RB1 tumor suppressor gene. Most patients with germline (hereditary) mutations have bilateral disease.

PURPOSE

We sought to quantify the mortality from second malignancies among long-term survivors of retinoblastoma and to identify factors that predispose to these deaths.

METHODS

A retrospective cohort study examined mortality among 1603 patients enrolled at 1 year after diagnosis of retinoblastoma during the period 1914-1984. Data on demography, family history, and retinoblastoma treatment were collected by medical chart review and questionnaire interview. Number of deaths, by cause, was compared with the corresponding expected figure based on U.S. mortality data for the general population for 1925-1990.

RESULTS

Follow-up was complete for 1458 patients (91%) for a median of 17 years after retinoblastoma diagnosis. A total of 305 deaths occurred, 167 of them from retinoblastoma. There were 96 deaths from second primary tumors (relative risk [RR] = 30), 21 from other known causes (RR = 1.0), and 21 from ill-defined or unknown causes. Statistically significant excess mortality was found for second primary cancers of bone, connective tissue, and malignant melanoma and benign and malignant neoplasms of brain and meninges. Among 919 children with bilateral retinoblastoma, 90 deaths from second primary tumors occurred (RR = 60). Deaths from second tumors were more frequent among females (RR = 39) than males (RR = 22) (P = .007). The cumulative probability of death from second primary neoplasms was 26% at 40 years after bilateral retinoblastoma diagnosis, and additional cancer deaths occurred thereafter. Radiotherapy for retinoblastoma further increased the risk of mortality from second neoplasms. An excess of mortality from a second cancer, not seen in prior studies, was found among the 684 children with unilateral disease (RR = 3.1; 95% confidence interval = 1.0-7.3).

CONCLUSIONS

These findings implicate germinal mutations in the retinoblastoma gene in second cancer mortality. Radiotherapy treatment for retinoblastoma appears to further enhance the inborn susceptibility to development of a second cancer.

IMPLICATIONS

Patients with retinoblastoma, particularly bilateral retinoblastoma, should have careful follow-up, and interventions should be developed to reduce mortality from a second cancer.

Adolescent body mass index and infertility caused by ovulatory disorder

OBJECTIVE

Our aim was to examine the association between body mass index at age 18 and subsequent primary ovulatory infertility.

STUDY DESIGN

A nested case-control study was conducted within a cohort of 116,678 female registered nurses residing in 14 U.S. states. Cases comprised 2527 married nulliparous nurses unable to become pregnant for at least 1 year because of ovulatory disorder; controls comprised 46,718 married parous nurses with no history of infertility. The risk of ovulatory infertility for women at different levels of body mass index at age 18 was compared with that for women whose body mass index at age 18 was 20 to 21.9 (median for the cohort). Logistic regression was used to adjust for age at infertility or first birth, year of birth, age at menarche, physical activity during ages 18 to 22, smoking at ages 15 to 19, ethnicity, alcohol use at ages 18 to 22, use of oral contraceptives before age 22, and diagnosis of diabetes mellitus.

RESULTS

Multivariate relative risks for infertility were: 1.2 (body mass index < 16), 1.1 (body mass index 16 to 17.9), 1.0 (body mass index 18 to 19.9), 1.0 (referent body mass index 20 to 21.9), 1.1 (body mass index 22 to 23.9), 1.3 (body mass index 24 to 25.9), 1.7 (body mass index 26 to 27.9), 2.4 (body mass index 28 to 29.9), 2.7 (body mass index 30 to 31.9), and 2.7 (body mass index > or = 32). The relative risks for all categories of body mass index above 23.9 were statistically significantly elevated. Greater body mass index at age 18 was a predictor of ovulatory infertility in women with and without a diagnosis of polycystic ovary syndrome.

CONCLUSION

These findings suggest that elevated body mass index at age 18, even at levels lower than those considered to be obese, is a risk factor for subsequent ovulatory infertility.

Increased maternal age and the risk of fetal death

BACKGROUND

Although the fetal death rate has declined over the past 30 years among women of all ages, it is unknown whether particular characteristics of the mother, such as age, still affect the risk of fetal death. We undertook a study to determine whether older age, having a first child (nulliparity), or other characteristics of the mother are risk factors for fetal death.

METHODS

We used data from the McGill Obstetrical Neonatal Database to evaluate risk factors for fetal death among all deliveries at the Royal Victoria Hospital in Montreal (n = 94,346) from 1961 through 1993. Data were available for two time periods (1961 through 1974 and 1978 through 1993); data for 1975 through 1977 have not been entered into the data base and were therefore not included. Using logistic regression, we estimated the effect of specific maternal characteristics and complications of pregnancy on the risk of fetal death.

RESULTS

The fetal death rate decreased significantly from 11.5 per 1000 total births (including live births and stillbirths) in the 1960s to 3.2 per 1000 in 1990 through 1993 (P < 0.001). Between these periods, the average maternal age at delivery increased from 27 to 30 years (P < 0.001), and the frequency of the diagnosis of diabetes and hypertension during pregnancy increased fivefold (P < 0.001). Nevertheless, after we controlled for these and other maternal characteristics, women 35 years of age or older continued to have a significantly higher rate of fetal death than their younger counterparts (odds ratio for women 35 to 39 years of age as compared with women < 30 years of age, 1.9; 95 percent confidence interval, 1.3 to 2.7; for those 40 or older, 2.4; 95 percent confidence interval, 1.3 to 4.5).

CONCLUSIONS

Changes in maternal health and obstetrical practice have resulted in a 70 percent decline in the rate of fetal death among pregnant women of all ages since the 1960s. Advancing maternal age, however, continues to be a risk factor for fetal death.

Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia

Water intoxication is a serious problem in many patients with chronic psychiatric illness. In an effort to determine the mechanism of this disorder, we investigated the osmoregulation of water intake and antidiuretic function in psychiatric patients with polydipsia and hyponatremia and in matched controls with psychiatric illness but neither polydipsia nor hyponatremia. We found that a water load suppressed plasma osmolality and vasopressin and urine osmolality in both groups, but that urinary dilution and free water clearance were impaired in the patients with hyponatremia, even though plasma levels of vasopressin and solute clearance were similar in the two groups. Moreover, during water loading and infusion of hypertonic saline, the plasma level of vasopressin was higher at any given plasma osmolality in the test patients than in the controls, indicating a downward resetting of the osmostat. Patients' estimates of the amount of water they desired were shown to correlate significantly with the amount of water consumed and, at any given level of plasma osmolality, appeared to be higher in the test patients than in the controls. We conclude that psychiatric patients with polydipsia and hyponatremia have unexplained defects in urinary dilution, the osmoregulation of water intake, and the secretion of vasopressin.

Cancer mortality following treatment for adult hyperthyroidism. Cooperative Thyrotoxicosis Therapy Follow-up Study Group

CONTEXT

High-dose iodine 131 is the treatment of choice in the United States for most adults with hyperthyroid disease. Although there is little evidence to link therapeutic (131)I to the development of cancer, its extensive medical use indicates the need for additional evaluation.

OBJECTIVE

To evaluate cancer mortality among hyperthyroid patients, particularly after (131)I treatment.

DESIGN

A retrospective cohort study.

SETTING

Twenty-five clinics in the United States and 1 clinic in England.

PATIENTS

A total of 35 593 hyperthyroid patients treated between 1946 and 1964 in the original Cooperative Thyrotoxicosis Therapy Follow-up Study; 91 % had Graves disease, 79% were female, and 65% were treated with (131)I.

MAIN OUTCOME MEASURE

Standardized cancer mortality ratios (SMRs) after 3 treatment modalities for hyperthyroidism.

RESULTS

Of the study cohort, 50.5% had died by the end of follow-up in December 1990. The total number of cancer deaths was close to that expected based on mortality rates in the general population (2950 vs 2857.6), but there was a small excess of mortality from cancers of the lung, breast, kidney, and thyroid, and a deficit of deaths from cancers of the uterus and the prostate gland. Patients with toxic nodular goiter had an SMR of 1.16 (95% confidence interval [CI], 1.03-1.30). More than 1 year after treatment, an increased risk of cancer mortality was seen among patients treated exclusively with antithyroid drugs (SMR, 1.31; 95% CI, 1.06-1.60). Radioactive iodine was not linked to total cancer deaths (SMR, 1.02; 95% CI, 0.98-1.07) or to any specific cancer with the exception of thyroid cancer (SMR, 3.94; 95% CI, 2.52-5.86).

CONCLUSIONS

Neither hyperthyroidism nor (131)I treatment resulted in a significantly increased risk of total cancer mortality. While there was an elevated risk of thyroid cancer mortality following (131)I treatment, in absolute terms the excess number of deaths was small, and the underlying thyroid disease appeared to play a role. Overall, (131)I appears to be a safe therapy for hyperthyroidism.

Body mass index and ovulatory infertility

Several studies have examined the association between body mass index and infertility. We compared body mass index in 597 women diagnosed with ovulatory infertility at seven infertility clinics in the United States and Canada with 1,695 primiparous controls who recently gave birth. The obese women (body mass index > or = 27) had a relative risk of ovulatory infertility of 3.1 [95% confidence interval (CI) = 2.2-4.4], compared with women of lower body weight (body mass index 20-24.9). We found a small effect in women with a body mass index of 25-26.9 or less than 17 [relative risk (RR) = 1.2, 95% CI = 0.8-1.9; and RR = 1.6, 95% CI = 0.7-3.9, respectively). We conclude that the risk of ovulatory infertility is highest in obese women but is also slightly increased in moderately overweight and underweight women.

A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata

OBJECTIVE

To investigate the risk of uterine leiomyomata in relation to reproductive factors and oral contraceptive use.

DESIGN

A prospective study.

SETTING

A cohort of female registered nurses from 14 states in the United States who completed mailed questionnaires in 1989, 1991, and 1993.

PATIENT(S)

Premenopausal nurses (n=95,061) aged 25-42 years with intact uteri and no history of diagnosed uterine leiomyomata or cancer in 1989.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Incidence of self-reported uterine leiomyomata confirmed by ultrasound or hysterectomy. In a sample of 243 cases, 93% of the self-reported diagnoses were confirmed in the medical record.

RESULT(S)

During 326,116 person-years of follow-up, 3,006 cases of uterine leiomyomata, confirmed by ultrasound or hysterectomy, were reported. After adjustment for other risk factors, the risk of uterine leiomyomata was significantly inversely associated with age at menarche, parity, and age at first birth, and positively associated with a history of infertility and years since last birth. The only notable association with any aspect of oral contraceptive use was a significantly elevated risk among women who first used oral contraceptives at ages 13-16 years compared with those who had never used oral contraceptives.

CONCLUSION(S)

Reproductive factors and oral contraceptive use at a young age influence the risk of uterine leiomyomata among premenopausal women.

Cancer incidence after retinoblastoma. Radiation dose and sarcoma risk

CONTEXT

There is a substantial risk of a second cancer for persons with hereditary retinoblastoma, which is enhanced by radiotherapy.

OBJECTIVE

To examine long-term risk of new primary cancers in survivors of childhood retinoblastoma and quantify the role of radiotherapy in sarcoma development.

DESIGN

Cohort incidence study of patients with retinoblastoma followed for a median of 20 years, and nested case-control study of a radiation dose-response relationship for bone and soft tissue sarcomas.

SETTING/PARTICIPANTS

A total of 1604 patients with retinoblastoma who survived at least 1 year after diagnosis, identified from hospital records in Massachusetts and New York during 1914 to 1984.

RESULTS

Incidence of subsequent cancers was statistically significantly elevated only in the 961 patients with hereditary retinoblastoma, in whom 190 cancers were diagnosed, vs 6.3 expected in the general population (relative risk [RR], 30 [95% confidence interval, 26-47]). Cumulative incidence (+/-SE) of a second cancer at 50 years after diagnosis was 51.0% (+/-6.2%) for hereditary retinoblastoma, and 5.0% (+/-3.0%) for nonhereditary retinoblastoma. All 114 sarcomas of diverse histologic types occurred in patients with hereditary retinoblastoma. For soft tissue sarcomas, the RRs showed a stepwise increase at all dose categories, and were statistically significant at 10 to 29.9 Gy and 30 to 59.9 Gy. A radiation risk for all sarcomas combined was evident at doses above 5 Gy, rising to 10.7-fold at doses of 60 Gy or greater (P<.05).

CONCLUSIONS

Genetic predisposition has a substantial impact on risk of subsequent cancers in retinoblastoma patients, which is further increased by radiation treatment. A radiation dose-response relationship is demonstrated for all sarcomas and, for the first time in humans, for soft tissue sarcomas. Retinoblastoma patients should be examined for new cancers and followed into later life to determine whether their extraordinary cancer risk extends to common cancers of adulthood.

Relation of tubal infertility to history of sexually transmitted diseases

We studied the history of sexually transmitted diseases in 283 nulliparous women diagnosed with infertility due to tubal adhesions or occlusion and 3,833 women admitted for delivery at seven collaborating hospitals. The adjusted risks of tubal infertility associated with the history of each sexually transmitted disease were estimated by the odds ratios obtained by multiple logistic regression. Women who reported prior infection with gonorrhea were at a significantly increased risk of tubal infertility (relative odds = 2.4, 95% confidence interval 1.3-4.4). In addition, the risk of tubal infertility was almost twice as high in women who recalled previous trichomoniasis compared with women with no such infection (relative odds = 1.9, 95% confidence interval 1.3-2.8). Furthermore, there was a trend of increasing risk with an increasing number of episodes of gonorrhea or trichomoniasis.

Divergent effects of two different doses of intranasal oxytocin on facial affect discrimination in schizophrenic patients with and without polydipsia

RATIONALE

Hyponatremia and dexamethasone resistance in polydipsic schizophrenic patients are attributable to changes in hippocampal-modulated antidiuretic and stress hormone activity, respectively. The relationship of the neuroendocrine findings to the psychiatric illness, however, is unknown. An impaired ability to identify facial emotions has been linked to core features of schizophrenia and to diminished levels of the closely related hormone, oxytocin, in the polydipsic subset. Intranasal oxytocin enhances facial affect discrimination in healthy subjects.

OBJECTIVE

The aim of this study is to explore if oxytocin reverses impaired facial affect discrimination in schizophrenic patients with, relative to that in patients without, polydipsia.

METHODS

Intranasal oxytocin (10 or 20 IU) and placebo were administered on three occasions to five polydipsic schizophrenic patients, eight nonpolydipsic patients, and 11 healthy controls. Subsequently, subjects rated the presence and intensity of six facial emotions.

RESULTS

Emotion recognition fell in both patient groups following 10 IU of oxytocin due to an increased propensity to identify all emotions regardless of whether they were displayed. By contrast, emotion recognition improved following 20 IU in polydipsic relative to nonpolydipsic patients due primarily to divergent effects on the bias to identify fear in nonfearful faces.

CONCLUSION

The effects of 20 IU oxytocin support the hypothesis that altered neuroendocrine function in polydipsic patients contributes to their psychiatric illness. Further studies are warranted to confirm these findings and assess if oxytocin treatment improves social functioning in this subset. This is the first psychopharmacologic study to compare different doses of oxytocin in the same subject, thus the significance of the opposing responses is unclear.

Infertility in women and moderate alcohol use

OBJECTIVE

The purpose of this study was to investigate the relationship between moderate alcohol intake and fertility.

METHODS

Interviews were conducted with 3833 women who recently gave birth and 1050 women from seven infertility clinics. The case subjects were categorized based on the infertility specialist's assignment of the most likely cause of infertility: ovulatory factor, tubal disease, cervical factor, endometriosis, or idiopathy. Separate logistic regression models were used to assess the relationship between alcohol use and each type of infertility, adjusted for age, infertility center, cigarette smoking, caffeine use, number of sexual partners, use of an intrauterine device (for tubal disease), and body mass index and exercise (for ovulatory factor).

RESULTS

We found an increase in infertility, due to ovulatory factor or endometriosis, with alcohol use. The odds ratio for ovulatory factor was 1.3 (95% confidence interval [CI] = 1.0, 1.7) for moderate drinkers and 1.6 (95% CI = 1.1, 2.3) for heavier drinkers, compared with nondrinkers. The risk of endometriosis was roughly 50% higher in case subjects with any alcohol intake than in control subjects (OR = 1.6, 95% CI = 1.1, 2.3, at moderate levels; OR = 1.5, 95% CI = 0.8, 2.7, at heavier levels).

CONCLUSIONS

Moderate alcohol use may contribute to the risk of specific types of infertility.

Psychotic exacerbations and enhanced vasopressin secretion in schizophrenic patients with hyponatremia and polydipsia

BACKGROUND

For unclear reasons, life-threatening water intoxication often coincides with acute psychosis in polydipsic schizophrenic patients with chronic hyponatremia. In contrast, most polydipsic schizophrenic patients are normonatremic and never manifest hyponatremia. To explore whether the effect of acute psychosis on water balance differs in these 2 schizophrenic subgroups, we compared their responses to drug-induced psychotic exacerbations.

METHODS

Matched polydipsic schizophrenic patients with (n = 6) and without (n = 8) hyponatremia were identified based on past and current indexes of fluid intake and hydration. A transient psychotic exacerbation was induced with an infusion of the psychotomimetic methylphenidate hydrochloride (0.5 mg/kg of body weight over a 60-second period). Antidiuretic hormone levels, subjective desire for water, and factors known to influence water balance were measured at 15-minute intervals for 2 hours.

RESULTS

Except for the expected differences in plasma osmolality and sodium, basal measures were similar in the 2 groups. Following methylphenidate administration, antidiuretic hormone levels increased more in the hyponatremic patients (P < .02), despite their consistently lower plasma osmolality (P < .007). No known or putative antidiuretic hormone stimulus could account for this finding. Only basal positive psychotic symptoms (P < .09) and plasma sodium (P < .18) were even marginally associated with the peak antidiuretic hormone responses, but neither factor could explain the difference in the response by the 2 groups.

CONCLUSION

Psychotic exacerbations are associated with enhanced antidiuretic hormone secretion, for unknown reasons, in schizophrenic patients with hyponatremia and polydipsia, thereby placing them at increased risk of life-threatening water intoxication.

Subfertility and the risk of low birth weight

OBJECTIVE

We evaluated the association between subfertility and low birth weight infants.

DESIGN

Women in this analysis participated in a cross-sectional investigation of maternal risk factors for adverse pregnancy outcomes.

SETTING

Medical and obstetric history and life style information were obtained from women who delivered at the Boston Hospital for Women, 1977 to 1980.

PATIENTS, PARTICIPANTS

Our analysis was restricted to nondiabetic married women who planned their pregnancies and subsequently delivered viable singletons (3,622). The 644 "subfertile" women (no conception during a year of unprotected intercourse) were compared with 2,978 "fertile" women (conception within 1 year).

MAIN OUTCOME MEASURE(S)

The relative risk of low birth weight was estimated using the cumulative incidence risk ratio.

RESULTS

After adjusting for confounding, the relative risk of delivering a low birth weight infant (less than 2,500 g) for subfertile women versus fertile women was 1.9 (95% confidence interval [CI], 1.3 to 2.8). The adjusted relative risk of delivering a term low birth weight (intrauterine growth retarded) infant was 2.3 (95% CI, 1.2 to 4.4).

CONCLUSIONS

In these data, subfertility is a predictor for low birth weight. The association may result from endocrinological, immunological, cervical, or other factors that interfere with optimal fetal growth.

Repetitive behaviors in chronically institutionalized schizophrenic patients

Repetitive dysfunctional behaviors (e.g., polydipsia, bulimia, hoarding, mannerisms) are frequently observed in chronically institutionalized schizophrenics, cause significant morbidity and are readily reproduced in animal models. The goal of this study was to assess the frequency and severity of these behaviors. Thirty-two chronic schizophrenics on an extended treatment unit were rated on the Elgin Behavioral Rating Scale, which includes eight repetitive behaviors and eight positive and negative symptoms. Forty-seven percent of the patients exhibited at least one severe, or 2 moderate, repetitive behaviors, while 63% exhibited at least one severe or 2 moderate positive or negative symptoms. The mean total score (+/- SD) on the eight repetitive behaviors (10.3 +/- 6.1) was about 2/3 that for the eight positive and negative symptoms (15.3 +/- 8.9, t = 4.1, p = .0001). Interrater reliability for the repetitive behaviors was similar to that for the positive and negative symptoms. Repetitive behaviors were positively related to male gender, white race and total length of hospitalization. Repetitive dysfunctional behaviors are frequently observed and can be reliably rated in chronically institutionalized schizophrenics.

Relation of female infertility to consumption of caffeinated beverages

Several studies have reported an association between caffeine intake and delay to conception. To study this relation further, the authors examined caffeine use in 1,050 women with primary infertility and 3,833 women who had recently given birth during the period 1981-1983 in the United States and Canada. The cases were separated by the cause of their infertility: ovulatory factor, tubal disease, cervical factor, endometriosis, or idiopathic infertility. The relative risks of each type of infertility associated with caffeine were calculated using separate logistic regression models and controlling for relevant confounding factors, such as age, center, cigarette smoking, lifetime number of sexual partners, alcohol consumption, contraception, body mass index, and exercise. A significant increase in the risk of infertility due to tubal disease or endometriosis was observed for the upper levels of caffeine intake, indicating a threshold effect. For tubal infertility, a relative risk of 1.5 (95% confidence interval (CI) 1.1-2.0) was found in women who consumed more than 7 g of caffeine per month as compared with those who consumed 3 g or less per month. For endometriosis, the relative risk was 1.9 (95% CI 1.2-2.9) in women who consumed 5.1-7 g/month and 1.6 (95% CI 1.1-2.4) in those with an intake of more than 7 g/month. These data suggest that caffeine deserves further study with regard to its effects on the female reproductive system.

Anemia and deficiencies of folate and vitamin B-6 are common and vary with season in Chinese women of childbearing age

Little is known about the micronutrient status of Chinese women of childbearing age. We assessed nonfasting plasma concentrations of folic acid, vitamin B-12, vitamin B-6 (as pyridoxal-5'-phosphate), hemoglobin (Hb), ferritin and transferrin receptor (TfR) in 563 nonpregnant textile workers aged 21-34 y from Anqing, China. All women had obtained permission to become pregnant and were participating in a prospective study of pregnancy outcomes. Mean (SD) plasma concentrations were 9.7 (4.1) nmol/L folic acid, 367 (128) pmol/L vitamin B-12, 40.2 (15.8) nmol/L vitamin B-6, 108 (12. 9) g/L Hb, 42.6 (34.2) microgram/L ferritin and 5.2 (2.7) mg/L TfR. Twenty-three percent of women had biochemical evidence of folic acid deficiency, 26% were deficient in vitamin B-6 and 10% had low vitamin B-12. Overall, 44% of women were deficient in at least one B vitamin. Although anemia (Hb < 120 g/L) was detected in 80% of women, only 17% had depleted iron stores (ferritin < 12 microgram/L); 11% had elevated TfR concentrations. Distinct seasonal trends were observed in the prevalence of moderate anemia (Hb < 100 g/L) and deficiencies of folic acid and vitamin B-6, with significantly lower concentrations of folate and Hb occurring in summer and lower concentrations of vitamin B-6 occurring in winter and spring than in other seasons. We conclude that deficiencies of folic acid, vitamin B-6 and iron were relatively common in this sample of Chinese women of childbearing age and were contributing to the high prevalence of anemia. Without appropriate supplementation, these deficiencies could jeopardize the women's health and increase their risk of adverse pregnancy outcomes.

Radioactive iodine therapy and breast cancer. A follow-up study of hyperthyroid women

A follow-up study of 1,762 hyperthyroid women who were treated at the Massachusetts General Hospital Thyroid Unit between 1946 and 1964 was conducted. The average length of follow-up was 17.2 years. A 1978 mailing address or a death certificate was located for 92% of the women, and 88% of 1,058 living patients responded to a mail questionnaire. The standardized mortality ratio (SMR) for all causes of death was 1.3 (95% confidence interval (CI) 1.2-1.4). The standardized mortality ratios for all malignant neoplasms and for breast cancer were 0.9 (95% CI 0.7-1.1) and 1.3 (95% CI 0.8-1.9), respectively. More deaths than expected were observed from endocrine and metabolic diseases (SMR = 1.8, 95% CI 1.2-2.7), circulatory system diseases (SMR = 1.4, 95% CI 1.3-1.6), and respiratory system diseases (SMR = 1.9, 95% CI 1.3-2.6). The standardized incidence ratios (SIR) for all malignant neoplasms and for breast cancer were 0.9 (95% CI 0.8-1.1) and 1.2 (95% CI 0.9-1.5), respectively. A nonsignificant excess breast cancer risk was observed 10 years after the onset of thyroid symptoms and was present at the end of 30 years of observation. A statistically significant excess number of pancreatic cancer cases (SIR = 2.0, 95% CI 1.0-3.7) and a nonsignificant excess of brain cancer cases (SIR = 2.3, 95% CI 0.7-5.3) were observed. Eighty per cent of the women were treated with radioactive iodine. When age at treatment and year of treatment were controlled, women who were ever treated with radioactive iodine had a standardized rate ratio for breast cancer of 1.9 (95% CI 0.9-4.1), compared with those who were never treated with radioactive iodine. Women who developed hypothyroidism as a result of their treatment for hyperthyroidism did not have an increased risk of developing breast cancer (SIR = 1.1, 95% CI 0.8-1.6).

Atypical pelvic inflammatory disease: can we identify clinical predictors?

OBJECTIVE

We used data from a large multicenter case-control study of tubal infertility to analyze further the relationship among demographic variables, behavioral measures, history of previous sexually transmitted diseases, and past contraceptive practices, for women with and without a history of pelvic inflammatory disease.

STUDY DESIGN

We identified 283 white women with tubal infertility who requested care at seven participating institutions. Of these women, 238 (84%) did not have a history of pelvic inflammatory disease ("atypical pelvic inflammatory disease") whereas 45 reported a history of pelvic inflammatory disease ("overt pelvic inflammatory disease"). We compared these groups with 1629 white women without a history of either infertility or pelvic inflammatory disease who were delivered of their first live-born child at the same institutions as the infertile cases.

RESULTS

Women with atypical pelvic inflammatory disease were demographically more like fertile control subjects and had behavioral characteristics midway between those of the overt pelvic inflammatory disease group and the fertile group. Both oral contraceptive and diaphragm use protected against tubal infertility for women with either atypical or overt pelvic inflammatory disease. Atypical pelvic inflammatory disease was related to a history of Trichomonas infection but not to a reported history of gonorrhea, genital herpes, or other vaginitis.

CONCLUSION

Atypical pelvic inflammatory disease is probably more common than its symptomatic counterpart. Whereas this condition is associated with some characteristics of a sexually transmitted infection, clinical predictors remain elusive.

Cannabis-related working memory deficits and associated subcortical morphological differences in healthy individuals and schizophrenia subjects

Cannabis use is associated with working memory (WM) impairments; however, the relationship between cannabis use and WM neural circuitry is unclear. We examined whether a cannabis use disorder (CUD) was associated with differences in brain morphology between control subjects with and without a CUD and between schizophrenia subjects with and without a CUD, and whether these differences related to WM and CUD history. Subjects group-matched on demographics included 44 healthy controls, 10 subjects with a CUD history, 28 schizophrenia subjects with no history of substance use disorders, and 15 schizophrenia subjects with a CUD history. Large-deformation high-dimensional brain mapping with magnetic resonance imaging was used to obtain surface-based representations of the striatum, globus pallidus, and thalamus, compared across groups, and correlated with WM and CUD history. Surface maps were generated to visualize morphological differences. There were significant cannabis-related parametric decreases in WM across groups. Similar cannabis-related shape differences were observed in the striatum, globus pallidus, and thalamus in controls and schizophrenia subjects. Cannabis-related striatal and thalamic shape differences correlated with poorer WM and younger age of CUD onset in both groups. Schizophrenia subjects demonstrated cannabis-related neuroanatomical differences that were consistent and exaggerated compared with cannabis-related differences found in controls. The cross-sectional results suggest that both CUD groups were characterized by WM deficits and subcortical neuroanatomical differences. Future longitudinal studies could help determine whether cannabis use contributes to these observed shape differences or whether they are biomarkers of a vulnerability to the effects of cannabis that predate its misuse.

Membrane-associated immunoglobulin of rabbit peripheral blood lymphocytes: allelic exclusion at the b locus

Light chain allotypic determinants were demonstrated on the surface of peripheral blood lymphocytes of rabbits. By means of a combined immunofluorescent and autoradiographic technique, a great majority of the individual lymphocytes of rabbits heteroxygous at the b locus were shown to have detectable quantities of only one allotype. A small proportion of lymphocytes appeared to possess both allelic forms of L chains.

What is the functional significance of hippocampal pathology in schizophrenia?

The hippocampal formation (HF) is one of the brain structures most consistently altered in schizophrenia, yet the contribution of HF pathology to severe mental illness is poorly understood. We present evidence that our current ignorance is attributable to the fact that the anterior HF is heavily involved in schizophrenia but has been inadequately examined by schizophrenia investigators. We propose that the anterior HF in humans, and its counterpart in rodents (ventral HF), constrain diverse responses to psychological stimuli and that disruption of this function contributes to schizophrenia. While current data suggest that hallmark symptoms of schizophrenia most likely result from the role of the anterior HF in the integrated neurocircuit that includes the prefrontal cortex, ventral striatum, and ventral tegmental area, better characterized and phylogenetically preserved neurocircuits may be similarly affected by anterior HF pathology and account for associated findings of the disorder. We propose that focusing on the impact of ventral HF pathology on these simpler circuits and functions in rodents may provide insight into the pathophysiology of severe mental illness in humans. We review several associated findings in schizophrenia to assess the likelihood that each could be a product of this putative anterior HF dysfunction and could therefore be productively studied in rodents by probing ventral HF function.

The mechanism of life-threatening water imbalance in schizophrenia and its relationship to the underlying psychiatric illness

Impaired water excretion was noted to coincide with psychotic exacerbations in the first decades of the past century. In the ensuing decades, life-threatening water intoxication and elevated plasma levels of the antidiuretic hormone, arginine vasopressin (AVP) were reported in a subset of persons with schizophrenia. Subsequent studies demonstrated that the osmotic set point for AVP secretion was transiently reset in these patients by an unknown process and that this was further exacerbated by acute psychosis. More recent studies indicate that the AVP dysfunction is a manifestation of a hippocampal-mediated impairment in the regulation of both AVP and HPA axis responses to psychological, but not other types of, stimuli. Of potential significance, is that schizophrenic patients without water imbalance exhibit the opposite pattern of responses. Preliminary data indicate those with water imbalance also demonstrate a closely linked deficit in central oxytocin activity which may account for their diminished social function. These latter behavioral deficits are perhaps the most disabling and treatment resistant features of schizophrenia, which recent studies suggest, may respond to oxytocin agonists. Together these findings support the view that schizophrenia is a heterogeneous disorder, and provide novel biomarkers and approaches for exploring the pathophysiology and treatment of severe mental illness.

Default mode functional connectivity is associated with social functioning in schizophrenia

Individuals with schizophrenia display notable deficits in social functioning. Research indicates that neural connectivity within the default mode network (DMN) is related to social cognition and social functioning in healthy and clinical populations. However, the association between DMN connectivity, social cognition, and social functioning has not been studied in schizophrenia. For the present study, the authors used resting-state neuroimaging data to evaluate connectivity between the main DMN hubs (i.e., the medial prefrontal cortex [mPFC] and the posterior cingulate cortex-anterior precuneus [PPC]) in individuals with schizophrenia (n = 28) and controls (n = 32). The authors also examined whether DMN connectivity was associated with social functioning via social attainment (measured by the Specific Levels of Functioning Scale) and social competence (measured by the Social Skills Performance Assessment), and if social cognition mediates the association between DMN connectivity and these measures of social functioning. Results revealed that DMN connectivity did not differ between individuals with schizophrenia and controls. However, connectivity between the mPFC and PCC hubs was significantly associated with social competence and social attainment in individuals with schizophrenia but not in controls as reflected by a significant group-by-connectivity interaction. Social cognition did not mediate the association between DMN connectivity and social functioning in individuals with schizophrenia. The findings suggest that fronto-parietal DMN connectivity in particular may be differentially associated with social functioning in schizophrenia and controls. As a result, DMN connectivity may be used as a neuroimaging marker to monitor treatment response or as a potential target for interventions that aim to enhance social functioning in schizophrenia. (PsycINFO Database Record

Clozapine restores water balance in schizophrenic patients with polydipsia-hyponatremia syndrome

Hyponatremia/hypoosmolemia causes marked morbidity and prolongs hospital stays in a significant subset of schizophrenic patients. Case reports with methodological limitations suggest clozapine ameliorates this water imbalance. To more conclusively assess this possibility, we completed a 24-week open-label study in 8 male polydipsic hypoosmolemic schizophrenic inpatients. Subjects were treated initially for 6 weeks with a conventional neuroleptic, which was replaced by 300, 600, and 900 (if tolerated) mg/day of clozapine for sequential 6-week periods. On clozapine, mean plasma osmolality rose an average of 15.2 mosm/kg (95% CI: 5.5-25.0). Dosage of 300 mg/day of clozapine was sufficient to normalize plasma osmolality and was generally well tolerated. Clozapine appears to be the first effective pharmacotherapy for severe water imbalance in schizophrenia.