Understanding health behaviors that modify the risk for obesity in ADHD

OBJECTIVE

Research provides support for the associated risk of inadequate sleep duration, limited physical activity, and excessive media use in attention-deficit/hyperactivity disorder (ADHD) and obesity. The present study aims to (1) examine the association between ADHD and overweight or obese status (OW/OB); (2) comprehensively examine sleep duration, physical activity, and media use as potential moderators of OW/OB; and (3) examine the moderating effects of these health behaviors cross-sectionally by comparing medicated youth with ADHD, unmedicated youth with ADHD, and youth without ADHD.

METHODS

Data were acquired from the 2018 and 2019 National Survey of Children's Health, a nationally representative survey of caregivers conducted across the United States. The current study used data for youth 11-17 years old with a final sample size of 26,644. Hours of sleep, physical activity, and media use per day were dichotomized based on national recommendation guidelines for each health behavior (i.e., either meeting or not meeting guidelines).

RESULTS

The OW/OB prevalence rate was 7% greater among unmedicated youth with ADHD than among medicated youth with ADHD. Medicated youth with ADHD and peers without ADHD had similar OW/OB rates. Among medicated youth with ADHD, physical activity, sleep duration, and media use did not contribute to OW/OB risk after controlling for family poverty level. However, among unmedicated youth with ADHD, meeting sleep duration guidelines was linked to a lower OW/OB risk.

CONCLUSION

Overall, findings suggest that clinical providers and parents may wish to prioritize improved sleep duration in the management of OW/OB risk in youth with ADHD.

Self-esteem in children and adolescents with and without attention-deficit/hyperactivity disorder: A meta-analytic review

Meta-analytic methods were used to examine global and domain-specific (i.e., academic, social, behavioral) self-esteem in children and adolescents with and without ADHD. Potential moderators of effect size heterogeneity were also examined via meta-regressions within a three-level approach. Findings from 49 aggregated global self-esteem effect sizes (ADHDN = 2500, TDN = 9448), 12 academic self-esteem effect sizes (ADHDN = 386, TDN = 315), 11 social self-esteem effect sizes (ADHDN = 258, TDN = 254), and 8 behavioral self-esteem effect sizes (ADHDN = 231, TDN = 211) suggest that children and adolescents with ADHD experience moderate global (ES = 0.46, p < .001), academic (ES = 0.60, p = .009), and social (ES = 0.67, p = .001) self-esteem impairments compared to children and adolescents without the disorder. The aggregated behavioral self-esteem effect size (ES = 0.20, p = .54), however, was not significant, and the global self-esteem effect size was markedly smaller compared to effect sizes for the academic and social domains. Further, examination of potential moderators of effect size heterogeneity indicated null effects for medication status, diagnostic complexity, informant, age, sex, comorbid psychopathology, and self-esteem dimension. Collectively, findings suggest that children and adolescents with ADHD do not hold a ubiquitous negative self-perception of difficulties across academic, social, and behavioral domains of functioning, and unexamined domains that are distal to ADHD may serve to bolster global self-esteem.

Social functioning in children with ADHD: an examination of inhibition, self-control, and working memory as potential mediators

Children with attention-deficit/hyperactivity disorder (ADHD) experience a host of social problems, in addition to significant impairments in behavioral inhibition, working memory, and self-control. Behavioral inhibition and working memory difficulties have been linked with social functioning deficits, but to date, most studies have examined these neurocognitive problems either in isolation or as an aggregate measure in relation to social problems, and none has considered the role of self-control. Thus, it remains unclear whether all of these executive functions are linked with social problems or if the link can be more parsimoniously explained by construct overlap. Fifty-eight children with ADHD and 63 typically developing (TD) children completed tests assessing self-control, behavioral inhibition, and working memory; parents and teachers rated children's social functioning. Examination of potential indirect effects with the bootstrapping procedure indicated that working memory mediated the relation between group membership (ADHD, TD) and child social functioning based on teacher but not parent ratings. Behavioral inhibition and self-control did not have direct relations with either parent- or teacher-rated social functioning. These findings point to important differences regarding how executive functioning difficulties manifest at school compared to home, as well as the specific executive function components that predict ADHD-related social difficulties.

Cognitive Disengagement Syndrome But Not ADHD Symptoms Increases Risk for Child Body Mass Index: Examination in a Sample of Clinically Referred Youth

Given the substantial increase in pediatric obesity rates in recent decades, its long-term stability, and its pervasive negative outcomes, continuous efforts to identify factors that may place children at increased risk for overweight or obesity (OW/OB) are essential. As such, the primary aim of the present investigation was to examine the extent to which symptoms of Cognitive Disengagement Syndrome (CDS; i.e., Sluggish Cognitive Tempo) relates to child body mass index (BMI) independent of Attention-Deficit/Hyperactivity Disorder (ADHD). The study is the first to examine whether CDS subdomains of slowed thinking, hypoarousal, and daydreamy is associated with BMI. Analyses included data from 72 clinically-referred children (46 males, 26 females) aged 4-12 years old (M = 8.41, SD = 2.48). CDS and ADHD were assessed using standardized parent-report rating scales, and children's BMI was collected at the time of encounter. Bayesian hierarchical regression models revealed no evidence that overall CDS symptoms or ADHD symptoms (overall and subdomain) predicted child BMI. However, models did provide moderate evidence that hypoarousal and daydream subdomains jointly predicted BMI independent of ADHD (BF10 = 19.28-21.87). The present study suggests that CDS is a risk factor for obesity in young children and future research is needed to inform clinical interventions and to provide further understanding of the relatively nuanced association between CDS symptoms and obesity.

Phonological working memory in children with and without ADHD: A systematic evaluation of recall errors

OBJECTIVE

Phonological working memory impairments associated with attention-deficit/hyperactivity disorder (ADHD) have garnered interest due to reliable evidence of moderate- to large-magnitude between-group (ADHD vs. control) effects, as well their association with a wide range of secondary impairments. However, previous studies are methodologically limited in their ability to identify potential underlying mechanistic processes. This study aimed to examine converging and diverging patterns of omission, intrusion, and transposition errors to parse-specific mechanistic processes that contribute to ADHD-related phonological working memory deficits.

METHOD

Fifty-four children with ADHD (45 males, nine females) and 65 typically developing (TD; 50 males, 15 females) children aged 8-12 (M = 9.62, SD = 1.52) years completed a computer-based phonological working memory task that aurally presented a random series of jumbled numbers and one letter. Children were instructed to verbally respond by stating the numbers from least to greatest, followed by the letter. Children's incorrect responses were coded as errors of omission, intrusion errors, or transposition errors.

RESULTS

Results indicated a significant moderate-magnitude between-group difference in total omission and transposition errors, and a significant small-magnitude between-group difference in total intrusion errors. An examination of specific error types supported evidence of ADHD-related deficits in reordering and updating central executive processes.

CONCLUSION

Collectively, these findings contribute to a more precise understanding of underlying mechanistic processes in ADHD-related working memory deficits and hold potential to inform the development of novel working memory metrics and working memory-based interventions for ADHD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Visuospatial working memory in attention-deficit/hyperactivity disorder: Characterizing path length and path crossings as mechanisms of impairment

OBJECTIVE

A growing body of research provides reliable evidence of moderate to large magnitude deficits in the visuospatial (VS) working memory (WM) of children with attention-deficit/hyperactivity disorder (ADHD), relative to typically developing (TD) children. Studies of ADHD-related Visuo-spatial Working Memory (VS-WM) functioning most often present sequential presentations of VS stimuli and examine general performance characteristics. Only a few studies have examined the effects of varying VS-WM task parameters on performance in children with ADHD, despite evidence from basic-cognitive research that indicates methodological heterogeneity in VS-WM task parameters yields significant performance variability that is associated with underlying mechanistic processes. This study is the first to examine the effect of the task parameters path characteristics and path crossings on performance in children with ADHD and TD children.

METHOD

School-aged children with ADHD (n = 50) and TD children (n = 59) completed a VS-WM task that varied by path lengths and path crossings.

RESULTS

Multilevel analyses indicated a negative effect of relatively long paths on VS-WM performance of both TD children and children with ADHD, and a negative effect of increasing path crossings that appears to be unique to TD children and dependent on path length.

CONCLUSIONS

Overall, findings appear to suggest that school-aged children engage in dynamic rehearsal of VS information (i.e., mental rehearsal of path sequences), rather than static rehearsal (i.e., rehearsal of a gestalt). Moreover, ADHD-related VS-WM deficits are most likely to yield real-world impairments when information is presented with relatively long path lengths. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attention-deficit/hyperactivity disorder and risk-taking: A three-level meta-analytic review of behavioral, self-report, and virtual reality metrics

Meta-analytic methods were used to examine ADHD-related risk-taking in children and adults, and to compare the magnitude of risk taking across behavioral, self-report, and virtual reality metrics. Potential moderators of effect size heterogeneity were also examined via a three-level multi-level approach and a hybrid meta-analytic/systematic review approach. Aggregated effect sizes obtained from 56 behavioral-task studies (82 effect sizes; ADHD_N = 2577; TD_N = 2606), 51 self-report studies (130 effect sizes; ADHD_N = 18,641; TD_N = 113,163), and 8 virtual reality studies (16 effect sizes; ADHD_N = 382; TD_N = 436) suggest that children and adults with ADHD exhibit moderately more risk-taking compared to children and adults without the disorder. Notably, the aggregated effect size obtained from virtual reality simulations (Hedges', g = 0.43) was 30-40% larger than effect sizes obtained from self-report and behavioral task metrics (Hedges' g = 0.31 and 0.27), respectively. Suboptimal Decision Making was the only significant moderator identified via multi-level modeling; however, comparison of subgroup effect sizes revealed potential moderating effects of ADHD presentation and trial-by-trial feedback on behavioral tasks. Collectively, findings suggest that ADHD is reliably associated with small to moderate magnitude greater risk-taking behavior and virtual reality simulations appear be the most sensitive currently available metric.

Emotion Regulation and Children With Attention-Deficit/Hyperactivity Disorder: The Effect of Varying Phonological Working Memory Demands

Objective: Findings from extant studies of the relationship between ADHD-related emotion regulation and working memory deficits have been equivocal, and their correlational designs preclude inferences about the functional relationship between working memory demands and emotion regulation. This study aimed to experimentally examine the functional relationship between varying working memory demands and ADHD-related emotion regulation deficits. Method: Overt emotion regulation behaviors were coded while children with and without ADHD completed experimental tasks that manipulated low and high working memory demands. Results: Compared with typically developing children, children with ADHD exhibited large-magnitude overall emotion expression deficits, disproportionately greater self-criticism during high working memory conditions, and disproportionately greater positive emotion expression during low working memory demand conditions. Conclusion: These findings suggest that working memory demands are functionally related to emotion regulation deficits exhibited by children with ADHD and may explicate variability of emotion regulation difficulties related to environmental demands.

Pigmented striae of the anterior lens capsule and age-associated pigment dispersion of variable degree in a group of older African-Americans: an age, race, and gender matched study

PURPOSE

To investigate pigmented striae of the anterior lens capsule in African-Americans, a potential indicator of significant anterior segment pigment dispersion.

METHODS

A group of 40 African-American subjects who exhibited pigmented lens striae (PLS) were identified from a non-referred, primary eye care population in Chicago, IL, USA. These subjects were then compared to an age, race, and gender matched control group relative to refractive error and the presence or absence of diabetes and hypertension.

RESULTS

The PLS subjects (mean age = 65.4 +/- 8.8 years, range = 50-87 years) consisted of 36 females and 4 males. PLS were bilateral in 36 (85%) of the 40 subjects. Among the eyes with PLS, 21 (55%) of 38 right eyes and 22 (61%) of 36 left eyes also had significant corneal endothelial pigment dusting, commonly in the shape of a Krukenberg's spindle. Ten (25%) of the PLS subjects had either glaucoma or ocular hypertension (7 bilateral, 3 unilateral). The presence of trabecular meshwork pigment varied from minimal to heavy. The mean +/- SD (range) refractive error of the PLS right eyes was +1.61 +/- 1.43D (-1.50 to +5.00D) and +1.77 +/- 1.37D (-1.00 to +5.00D) for the left eyes. Based on these data, the PLS right eyes were +1.63D (Student's t, p = 0.0001; 95% CI = +0.82 to +2.44D) more hyperopic on average than the control right eyes, and the PLS left eyes were +1.77D (p = 0.0001; 95% CI = +0.92 to +2.63D) more hyperopic on average than the control left eyes. Trend analysis showed a gradually increasing likelihood of PLS with increasing magnitude of hyperopia in both eyes (Mantel-Haenszel chi-square, p = 0.001). Among PLS subjects, 24 (60%) of 40 were hypertensive and 9 (23%) of 40 were diabetic. However, these proportions were not significantly different (two-tailed Fisher's exact test; hypertension: p = 0.30; diabetes: p = 0.70) from the randomly selected controls.

CONCLUSIONS

Among our African-American group, which consisted predominately of females >50 years of age, the likelihood of PLS increased with increasing hyperopic refractive error. This finding is consistent with the possibility that PLS may, in some circumstances, indicate a significant pigment dispersal process due to iris-lens rubbing that may be associated with crowding of anterior segment structures. Additional study is warranted to further assess the nature of PLS, their precise relationship with an age-related pigment dispersal process, and their true significance as a risk factor for development of glaucoma.

Retrospective, longitudinal, and cross sectional study of visual acuity impairment in choroideraemia

BACKGROUND/AIMS

Few studies have reported on the change in visual acuity (VA) in patients with choroideraemia. In order to determine the degree and rate of VA impairment associated with this disease, the central VA was analysed in a large group of patients with choroideraemia.

METHODS

The authors completed a retrospective, cross sectional review of 115 patients with choroideraemia from three tertiary care centres. A longitudinal analysis was performed on 45 of these patients who met the inclusion criteria of at least three visits over a minimum period of 4.5 years. Multiple linear regression analysis was used to explore the 5 year rate of VA change while controlling for initial VA and initial age. Multiple logistic regression was also used to investigate VA impairment.

RESULTS

In the cross sectional group (n = 115), 84% (87/103) of patients under the age of 60 had a VA of 20/40 or better while 33% (4/12) of patients 60 years of age or older had a VA of 20/200 or worse at their most recent visit. The majority of the patients (93%) in the longitudinal subgroup of 45 patients had a VA of 20/30 or better at their initial visit. The mean 5 year rate of VA change was 0.09 logMAR equivalent (approximately one line on the Lighthouse chart).

CONCLUSION

In this cohort of patients with choroideraemia, there was typically a slow rate of VA loss and the prognosis for central VA retention was, as a group, favourable until the seventh decade.

Retrospective longitudinal study of visual acuity change in patients with retinitis pigmentosa

PURPOSE

To determine the extent that clinically evident macular lesions in patients with retinitis pigmentosa (RP) help to establish their prognosis for visual acuity (VA) retention.

METHODS

The records of 182 patients with RP were reviewed. The macular lesion status at the initial examination was determined to be no lesion, a bull's-eye atrophic lesion, or a geographic atrophic lesion. Multiple linear regression analysis was used to evaluate the relationship of initial VA, macular lesion type, and RP genetic subtype to predict the VA change per 5-year period.

RESULTS

The regression effect of lesion type on the VA change was statistically significant (P < 0.0001). Patients with no macular lesion had a predicted 5-year change of less than 1 line, whereas those with either a bull's-eye or geographic atrophic lesion had a predicted 5-year change of three to four lines. The 5-year changes were not related to a patient's age or level of VA at initial presentation, when controlling for type of macular lesion.

CONCLUSION

By examining longitudinal data, the authors found that the presence or absence of a macular lesion at the patient's initial visit was an important determinant of VA loss in this cohort of patients with RP. These findings are of value when counseling patients with RP regarding their prognosis for preservation of VA.

Anterior chamber angle anomalies associated with signs of pigment dispersion in a group of black probands and their first-degree relatives

PURPOSE

To evaluate the presence of iridocorneal angle anomalies associated with signs of pigment dispersion among a group of black probands and their first-degree relatives.

METHODS

Eleven blacks who exhibited pigment dispersion syndrome (PDS) signs, including Krukenberg's spindles, moderate-to-heavy trabecular meshwork pigmentation, and peripheral lenticular/zonular pigmentation, received a complete eye examination that included gonioscopy. Overt iridocorneal angle abnormalities other than pigment deposition were photo-documented. Twenty-two first-degree relatives (6 siblings, 15 children, and 1 parent) of these probands underwent similar examination.

RESULTS

Among the subjects, 5 of 11 probands (age range 13 to 59 years) and 4 of 22 relatives (age range 14 to 51 years) exhibited definite angle anomalies. The nine subjects with angle anomalies belonged to 7 of 11 separate families. The four relatives with angle anomalies did not have PDS according to our criteria, but two other relatives from two additional families did have signs consistent with clinical PDS. Types of angle anomalies included (1) peripheral anterior synechia-like lesions; (2) a prominent concavity of the peripheral iris at the 6-o'clock meridian; (3) a whitish, thread-like band of tissue near the iris base; (4) a prominent, externally-visible Schwalbe's line at the 6-o'clock meridian; and (5) a prominent, web-like confluence of exaggerated iris processes 360 degrees along the angle wall. Iris processes and prominent Schwalbe's lines were not considered abnormal or anomalous unless they were clearly atypical.

CONCLUSIONS

Iridocorneal angle anomalies, other than pigment deposition, were common among our black group who exhibited signs of pigment dispersion as well as among their first-degree relatives. Further consideration should be given to the possibility that among some patient groups, overt goniodysgenesis could be part of a constellation of signs indicative of a pigment dispersion syndrome. Potentially, clinically detectable goniodysgenesis could prove to be a useful marker to identify certain subjects who carry PDS genetic traits but who have not expressed complete phenotypical disease.

Screening for stimulant use in adult emergency department seizure patients

OBJECTIVE

The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients.

METHODS

This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers.

RESULTS

Fourteen of 248 (5.6%, 95% CI 2.7%-8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI 0-1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005).

CONCLUSIONS

During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.

Heritage characteristics reported by a group of African-Americans who exhibit the pigment dispersion syndrome: a case-control study

PURPOSE

To investigate the racial heritage of a group of African-Americans who exhibit the pigment dispersion syndrome (PDS).

SUBJECTS AND METHODS

Ten unrelated African-American PDS patients (age range 13-59) from a primary eye care population in Chicago, Illinois, USA, were interviewed to determine their racial heritage. Since Caucasian and Native American heritage were commonly reported, 101 unaffected African-American control subjects (age range 18-55) were also interviewed to determine the reported frequency of these specific racial heritage characteristics.

RESULTS

Some degree of Caucasian heritage was reported by 100% of the PDS subjects and by 46.5% of controls. Native American heritage was reported by 90% of the PDS subjects and by 71.3% of controls. Based on these data, the PDS subjects were significantly more likely to report Caucasian heritage (Fisher's exact test, P=0.001) but they were not significantly more likely to report Native American heritage (P=0.282). In addition, the PDS subjects were significantly more likely to report Caucasian heritage from both parents (P=0.024) and more likely to report a combination of both Caucasian and Native American heritage (P=0.0006) than corresponding controls. In general, the PDS subjects had 'light' or 'medium' complexions.

CONCLUSION

Results from this analysis are consistent with the hypothesis that non-African heritage, particularly Caucasian, is likely to be prevalent in the background of African-Americans who exhibit PDS. It is suggested that non-African heritage may not only be important for the transference of PDS causing genes, but it may also influence factors such as degree of iris pigmentation and rigidity which could influence iris contour and the subsequent expression of PDS in those who are genetically predisposed. Further investigation is needed to study the factors that influence the expression and severity of PDS among African-Americans, a population which traditionally has been considered to be rarely affected by this condition.

Iris transillumination defects in the pigment dispersion syndrome as detected with infrared videography: a comparison between a group of blacks and a group of nonblacks

BACKGROUND

Infrared image analysis has been reported to be the most sensitive method to detect iris transillumination defects (ITDs) associated with the pigment dispersion syndrome (PDS). Although a common sign of PDS in patients with lighter irides, ITDs that are demonstrated with standard slit lamp examination are frequently absent in blacks with the disease. This absence may lead to confusion in diagnosis; therefore improved methods of evaluation could be beneficial. Although infrared image analysis has been investigated in nonblacks, it has not been applied to a group of blacks with the condition.

METHODS

Six blacks (11 eyes, all irides brown) with PDS and eight nonblacks (15 eyes, 10 blue irides, 5 brown irides) with PDS underwent analysis. ITDs were searched for with traditional slit lamp examination and with infrared videography.

RESULTS

Among the blacks, 2 of 11 eyes (18%) showed ITDs via infrared analysis, a frequency that was significantly lower (p < 0.001) than the frequency exhibited among the nonblacks (100%) when examined with the same technique. Standard slit lamp examination also showed a significantly lower frequency of ITDs among the blacks compared to the nonblacks (p < 0.001). Infrared videography detected ITDs at least one grade higher in 1 of 11 eyes (9%) among the black group and in 7 of the 15 eyes (47%) among the nonblacks. Using the Wilcoxon signed ranks test, the difference in the ability of infrared videography to detect and rank the iris defects in the nonblack PDS group was significantly greater when compared to standard slit lamp examination (p = 0.011), but infrared analysis did not increase detection or change the mean ranking of those in the black group (p = 0.317).

CONCLUSION

In this group of patients, infrared videography did not significantly improve the detection and visibility of ITDs in blacks, as it did in the nonblacks. The frequency that ITDs were detected with standard slit lamp examination and with infrared videography was significantly greater in the group of nonblacks compared to the blacks who exhibited PDS.

The inheritance of the pigment dispersion syndrome in blacks

PURPOSE

Evidence has indicated that pigment dispersion syndrome (PDS) is inherited as an autosomal dominant disorder in white patients, often with a high degree of penetrance. Because heredity patterns in blacks are unknown, an investigation was carried out to study inheritance of PDS in this population.

METHODS

Six unrelated black adults (5 women, 1 man, age range 43-60 years) with PDS were identified from a primary eye care population at an inner city teaching clinic in Chicago, Illinois. Nineteen first-degree relatives (all siblings or children; age range 18-52 years) of these patients subsequently underwent thorough eye examination to look for signs of PDS.

RESULTS

Among the relatives, two (12%) showed evidence of the condition (these two patients belonged to different families): one was a 42-year-old daughter of a 60-year-old proband, and the other was the 49-year-old sister of a 47-year-old proband. Both exhibited definite signs of PDS in one eye only.

CONCLUSION

Evidence of expression of PDS among family members of black probands with PDS is provided. Incomplete penetrance of PDS among the black pedigrees may be suggested by these data.

Ultrastructural interactions in the microvasculature of human endometrial adenocarcinoma

OBJECTIVES

Our purpose was to study the ultrastructural morphology of the microvasculature of human endometrial adenocarcinoma and to determine the effect of this malignancy on cell-to-cell communication between the components of the microvasculature and with the other tissue compartments of human endometrium. Methods. Multiple cases of human endometrial adenocarcinoma were studied and graded by light microscopy. Six cases of Grade I and six cases of Grade II were selected. Two blocks per case were studied ultrastructurally.

RESULTS

In contrast to our expectation that the ultrastructure of tumor vessels would suggest a great deal of proliferation and new vessel formation, we found that tumor vessels displayed a high degree of cellular differentiation, in the form of numerous and varied cell-to-cell contacts, and large amounts of protein production.

CONCLUSIONS

The morphology of the microvasculature of endometrial adenocarcinoma suggests an active rather than passive role in tumor vessels.

Clinical signs of the pigment dispersion syndrome in blacks

BACKGROUND

The pigment dispersion syndrome (PDS) is considered rare in blacks, and minimal literature exists concerning the condition in this patient population. The diagnosis of PDS in blacks may present unique challenges because some of the typical clinical signs that are present in whites, including iris transillumination defects, posterior iris bowing, and noticeable anterior iris stromal pigment dusting, may not occur as commonly. Diagnosis can be particularly difficult when neither these signs nor significant corneal endothelial pigmentation exists. Although zonular and peripheral lens pigment has been found to be consistently present in whites with PDS, attention has not been given to this as a potentially important diagnostic sign in blacks.

METHODS

From among a primary care population, we identified and studied 7 patients (13 eyes) who exhibited moderate to heavy trabecular meshwork (TM) pigmentation, as well as zonule and/or peripheral lens pigmentation. Patients were identified during routine clinical care provided by one of the authors, as well as from notification by other practitioners. All patients received complete eye examination and other signs of PDS were looked for.

RESULTS

Four males and 3 females were identified, their average age being 37 years (range = 15 to 51) at the time of their initial identification. All but one patient was myopic (average approximately -2.50 D spherical equivalent). Iris transillumination defects were present in only one eye of one patient, and no eyes showed overt posterior iris bowing, although the iris contours were usually flat and the anterior chambers appeared relatively deep. Corneal endothelial pigmentation was frequently barely detectable and could not be relied on as a predictor of trabecular meshwork or lenticular pigmentation. Glaucoma, or a suspicion of glaucoma due to increased intraocular pressure (IOP) or cupping, was common among the group. Using heavy TM pigmentation as well as any degree of zonular and/or peripheral lenticular pigmentation as a criteria for the diagnosis of PDS, we calculated the prevalence of PDS among blacks in a nonreferred primary care population (> age 7) to be at least 15 cases per 10,000.

CONCLUSIONS

More investigation is needed to study the clinical presentation of PDS in blacks because it may be substantially different than in whites. Zonular and peripheral lenticular pigmentation may be a particularly useful diagnostic sign of PDS in blacks, especially in those cases where other traditional signs, including iris transillumination defects, pronounced corneal endothelial pigmentation, posterior iris bowing, and visible anterior iris stromal pigment dusting, are absent. The "classic" variety of PDS may be more common among blacks than previously recognized.

Ultrastructure of the microvasculature in human endometrial hyperplasia

OBJECTIVE

Our purpose was to determine the effect of hyperplasia on cell-to-cell communication in the microvasculature of the human endometrium.

STUDY DESIGN

Ten biopsy specimens of simple and complex hyperplasia of the human endometrium were investigated by electron microscopy.

RESULTS

The microvasculature of the hyperplastic endometrium shows morphologic disorder. The extracellular matrix is altered, and cell death is widespread. Intercellular contact is infrequent or absent.

CONCLUSIONS

These results are in marked contrast to the ultrastructure of the normal microvasculature. The complex cell-to-cell interaction observed in normal tissue appears lost. This report, combined with others, indicates that cell-to-cell contact is sparse in hyperplastic endometrium.

The nuclear channel system in endometrial adenocarcinoma exposed to medroxyprogesterone acetate

The nuclear channel system (NCS), giant mitochondria and subnuclear glycogen form a triad of ultrastructural features observed in normal human endometrial epithelium in response to progestational steroids. Both the giant mitochondria and subnuclear glycogen have been described in endometrial adenocarcinoma, but the NCS has not. This article reports the development of the NCS in adenocarcinoma treated with medroxyprogesterone acetate. Previous studies suggest that the NCS in normal tissue is a response to the acyl group in the 17-beta position of the D-ring of some progestational steroids, such as medroxyprogesterone acetate. Medroxyprogesterone acetate was administered to 12 postmenopausal women with endometrial adenocarcinoma. Hysterectomies were performed 8 to 20 days after treatment. Pretreatment specimens were also obtained on 8 of the 12 patients. Using standard electron microscopy procedures, light microscopy on plastic semithin sections was first used to confirm the presence of tumor. Thin sections of malignant endometrium were prepared and evaluated ultrastructurally for progestational alterations. Abnormal giant mitochondria and subnuclear glycogen were found both before and after treatment. The third element of the triad, the NCS, was not observed in any of the available pretreatment biopsies, but was seen in three of the treated specimens. Thus it appears that the NCS is a response to the given progesterone therapy.

Pigmentation of the posterior lens capsule central to Wieger's ligament and the Scheie line: a possible indication of the pigment dispersion syndrome

Observation of pigment deposition on the posterior lens central to Wieger's ligament and the position of the so-called Scheie line is reported as a clinical sign of the pigment dispersion syndrome (PDS). Although abnormal pigmentation of the posterior lens surface is well-known to occur as scattered deposition among the zonule insertions as well as in the shape of a line formed within the crevice just anterior to the junction between the posterior capsule and the anterior hyaloid face, pigmentation has not been well-known to occur more centrally, nearer the polar capsular region. Pigment in this location is a relatively unknown finding in PDS and may lead to suspicion and diagnosis of this disorder.

Validation of a rapid urine screening assay for cocaine use among pregnant emergency patients

OBJECTIVES

To determine the accuracy of the OnTrak rapid urine latex agglutination immunoassay (AIA) for testing pregnant ED patients for the cocaine metabolite benzoylecgonine (BE), and to determine the frequency of urine BE in pregnant ED patients and the association of test results with patient demographics.

METHODS

A test performance evaluation was conducted using an inception cohort of pregnant patients at an urban teaching hospital ED. Patients with positive urine chorionic gonadotropin tests who had adequate remaining urine samples were studied. Patient demographics, ED diagnoses, and assay results were recorded without patient identifiers. Urine was tested using the rapid AIA. The first 150 samples were confirmed using a second immunoassay and gas chromatography with a nitrogen phosphorus detector. All positive samples also were confirmed with thin-layer chromatography, and quantification by gas chromatography-mass spectrometry.

RESULTS

Twenty of 342 (5.9%, 95% CI 3.4-8.4%) pregnant patients had urine samples positive by AIA testing for BE. Confirmation testing demonstrated no false-positive or -negative AIA result. Positive test results were not associated with specific patient diagnoses or demographics.

CONCLUSIONS

ED screening for cocaine use among pregnant patients can be accurately performed using the OnTrak AIA for BE. In the ED population screened, 5.9% of the pregnant women had urine samples positive for BE.

Coronary artery morphologic features after coronary rotational atherectomy: insights into mechanisms of lumen enlargement and embolization

The coronary arteries and myocardium from two patients who died after coronary rotational atherectomy were analyzed to gain insights into the mechanisms of lumen enlargement and to document embolization of calcified plaque. Rotational atherectomy resulted in sharp cuts in plaque, producing a relatively smooth luminal surface. When extensive nodular calcific atherosclerosis was present, the luminal surface was focally uneven with exposure of jagged calcified plaque to blood flow. Deep plaque fissures and medial dissections were also seen. These fissures may have been created by the rotoblator or by adjunctive balloon angioplasty. Multiple calcific atheroemboli were present after rotoblator use in plaques containing extensive nodular calcification; in moderately calcified plaque only one small atheroembolus was found. Thus embolization of calcified plaque can occur after rotational atherectomy and may correlate with the severity of plaque calcification. Rotational atherectomy produces a focally smooth, sharp-edged, luminal surface, a lumen enlargement mechanism different from balloon angioplasty.

Ultrastructural cell-to-cell interactions in hyperplastic endometrial stroma

In hyperplastic endometrial stroma, cell-to-cell contacts are infrequent. Those that are present are not well developed and may appear degenerative. Significant amounts of extracellular matrix further impede contact. The cells of hyperplastic endometrial stromal are, for the most part, poorly differentiated and both apoptosis and necrosis are common. Fibroblast-like cells make up most of the increased cellularity, with few endometrial granulocytes or other cells types.

Stromal-epithelial communications in hyperplastic human endometrium

OBJECTIVE

Our objective was to assess the cell-to-cell contacts in hyperplastic human endometrium and to compare them with contacts in normal endometrium.

STUDY DESIGN

Hyperplastic endometrial samples (five with simple hyperplasia and five with complex hyperplasia) without atypia by light microscopy were studied with transmission electron microscopy. The cell-to-cell contacts, basal lamina, and epithelial-to-stromal compartment contacts were studied and compared with these same areas in normal endometrium.

RESULTS

Only infrequent gap junctions between epithelial cells were seen. Other epithelial contacts were also greatly reduced when compared with normal epithelium. Cell-to-cell contacts between the epithelial compartment and the stromal compartment were rare and degenerative in configuration. An increase in extracellular matrix and various alterations in the basal lamina appears to contribute to a decrease in cell-to-cell contacts.

CONCLUSIONS

Compared with normal endometrium, hyperplastic endometrium demonstrated far fewer cell-to-cell contacts. The basal lamina and extracellular matrix were altered in such a fashion that communication between the stromal and epithelial compartments appeared to be impaired. Stromal and epithelial cells rarely were in contact. Those contacts present were less complex and the majority were degenerative. Hyperplasia without atypia demonstrated a much lower amount of intercellular communication than normal endometrium.

Current status of magnetic resonance in radiologic diagnosis of foot and ankle injuries

Magnetic resonance imaging can provide unique advantages in evaluation of foot and ankle disorders. Among these advantages are lesion localization, sensitivity in differentiation, and evaluation of ligaments, tendons, and osseous abnormalities.

The experience of dyspnea in late-stage cancer. Patients' and nurses' perspectives

We examined the phenomenon of dyspnea during the last weeks of life as it is experienced by patients with cancer and understood by the nurses providing their care. The literature on late-stage cancer suggests a discrepancy between the prevalence of this symptom and the degree to which it is considered clinically significant. Using a range of descriptive and interpretive approaches, we sought to interpret that discrepancy through an understanding of how patients and nurses interpret the nature and meaning of this serious and distressing symptom. Data sources included a pencil-and-paper survey of late-stage cancer patients, chart audit of a population of late-stage cancer patients in a metropolitan home-care hospice program, and intensive interviews with selected patients and nurses. The findings showed that although dyspnea seems to be a significant clinical problem for patients in late-stage cancer, and although effective intervention and management strategies are available, dyspnea often goes unreported by patients and unnoticed by healthcare professionals.

Light-induced amaurosis associated with carotid occlusive disease

A 74-year-old man with the isolated complaint of uniocular transient visual loss after exposure to bright light was found to have severe ipsilateral, atherosclerotic carotid occlusive disease. Signs of ocular ischemia that were present included slightly reduced visual acuity, mild afferent pupillary defect, lowered intraocular pressure, increased photostress recovery time, and reduced opthalmodynamometry values on the affected side. After a subclavian to internal carotid artery bypass procedure, the patient's symptoms resolved completely and his ocular signs returned to normal. This patient's initial symptom, referred to as light-induced amaurosis (LIA), is an unfamiliar manifestation of the ocular ischemic syndrome. We discuss the condition and summarize the literature.

Ultrastructure of the microvasculature in the human endometrium throughout the normal menstrual cycle

In the early proliferative phase endometrial capillary basal lamina is loosely formed and discontinuous. It becomes more distinct in the late proliferative phase and develops whorled extensions that include pericytes in the early secretory to midsecretory phase. Throughout the cycle both endothelial cells and pericytes possess cytoplasmic processes that extend through discontinuities in the basal lamina and make contact with each other. These contacts may be simple or complex. They become more elaborate as the cycle progresses to the midsecretory phase. Endothelial cells show progressive but heterogeneous differentiation into the midsecretory phase, with individual cell hypertrophy. In the late-secretory phase the endometrial stroma and the basal lamina are characterized by widespread degeneration, and the cell-to-cell contacts sharply decrease. However, endothelial cells remain relatively intact.

Bilateral monocular diplopia secondary to occult diabetes mellitus

A 68-year-old man presented with transient, bilateral, vertical, monocular diplopia as an initial manifestation of diabetes mellitus. The diplopia was determined to be of lenticular origin, but was not found to be secondary to the usual refractive changes. Rather, it is presumed to be due to prismatic alterations caused by index of refraction differences within the crystalline lenses. It is not known what other factors relate to the development of this type of diplopia in the diabetic patient.

Idiopathic multiple serous detachments of the retinal pigment epithelium: a report of two cases

A relatively uncommon entity is described which is characterized by idiopathic serous detachments of the retinal pigment epithelium (RPE). In contrast to RPE detachments associated with the spectrum of age-related macular degeneration and other choroidal diseases, the visual prognosis in this entity is usually good. In some respects, idiopathic serous RPE detachments display characteristics similar to idiopathic central serous chorioretinopathy and could be a variant thereof. The differential diagnosis also includes multifocal Best's vitelliform dystrophy.

Intercellular contacts between stromal cells in the normal human endometrium throughout the menstrual cycle

Increasing differentiation in the human endometrium is associated with an apparent decrease in intercellular contacts between endometrial stromal cells

TAC use and absorption of cocaine in a pediatric emergency department

The topical anesthetic TAC (tetracaine 0.5%, adrenaline 0.05%, cocaine 11.8%) has been reported to be effective in pain control for local procedures. However, it has the potential for cocaine toxicity by absorption through an open wound. A study was undertaken to assess the systemic absorption of cocaine and its metabolites when TAC is used as a local anesthetic. Fifty-one children, 1 to 14 years of age, were enrolled in the study. Plasma for cocaine and/or its metabolite levels was available from 46 children and obtained 20 to 40 minutes after the topical anesthetic was applied. No plasma sample had detectable parent cocaine levels; however, 26 (56.5%) had cocaine metabolite levels. Ecgonine methylester levels were detected in plasma from six children and ranged from 59 to 985 ng/mL. Benzoylecgonine levels were detected in none of 19 specimens not preserved with sodium fluoride, and in 23 of 27 specimens to which sodium fluoride had been added. Benzoylecgonine levels ranged from 40 to more than 600 ng/mL. No clinical sign of cocaine toxicity was observed in any child.

Experience with the Groshong long-term central venous catheter

A study of the Groshong catheter in a gynecologic oncology population is presented, describing the catheter's ease of insertion, and patient acceptance and compliance in catheter care. From December 1985 through November 1987, 72 Groshong catheters were inserted in 67 patients. The Groshong differs from conventional Hickman-type catheters in design and maintenance. Thirty-two of 72 catheters (44%) were inserted under local anesthesia. The remaining catheters were inserted under general anesthesia at the time of major gynecologic procedures. None of the cases required fluoroscopy. The insertion technique is less traumatic than conventional approaches because of a stainless steel tunneling device. The median duration of use was 191 days. There were no cases of pneumothorax or catheter occlusion. Catheter removal was required in four cases with skin infection unresponsive to local therapy and in two cases with bacteremia. One patient developed thrombosis of the right subclavian vein but was treated without catheter removal. One patient with a skin infection at the exit site accidentally dislodged her catheter. The overall complication rate was 11% (8 of 72 cases).

Changes in nuclear and nucleolar areas of endometrial glandular cells throughout the menstrual cycle

Reproducible measures of the ultrastructural changes occurring throughout the normal human menstrual cycle are useful for defining and differentiating between normal and pathological states. Glandular endometrial functionalis epithelium obtained from five menstrual cycle subphases (early and late proliferative; and early, middle and late secretory) has been quantitated and compared for changes in nuclear and nucleolar size. These analyses indicate that (a) nuclear area significantly increases in the late secretory subphase, perhaps a requirement of endometrial regeneration; (b) nucleolar area peaks during the early secretory subphase, a necessary prelude for the later increased secretory activity; and (c) nucleolar area declines in the middle and late secretory subphases, probably due to falling hormone blood levels late in the cycle. In the proliferative phase, the majority of cells containing large nuclei and nucleoli have a relatively undeveloped cytoplasm, while the cytoplasm of those in the secretory phase contains glycogen. These cells were termed Stage 1 and 2 cells, respectively. The late secretory subphase contains some degenerating mature epithelial cells with large nuclei and small nucleoli as well as differentiated and regenerating cells with larger nucleoli. These measures establish a baseline of the normal changes in nuclear and nucleolar size as they occur throughout the normal human menstrual cycle.

Iris microhemangiomas

Iris microhemangiomas (IM) are benign proliferations of small, twisted blood vessels along the pupillary margin. They are usually bilateral and appear to be developmental in nature. IMs most commonly occur in patients with myotonic dystrophy and adult-onset diabetes mellitus, but have also been associated with respiratory disease, congential heart disease, and central retinal vein occlusion. Additionally, they may be found in individuals without obvious ocular or systemic abnormality. The etiology remains obscure. In this report, illustrative cases are followed by a brief discussion outlining typical clinical manifestations, etiological considerations, and possible implications.

Interaction of epithelial and stromal cells in vaginal adenosis

Two types of direct contact between epithelial and stromal cells in patients with vaginal adenosis are documented in electron micrographs. In the first type, epithelial cells send cytoplasmic extensions through the basal lamina to achieve, at times, complete fusion with fibroblasts in the stromal compartment. In the second type, mast cells act as intermediaries between the epithelial and stromal compartments.

Ultrastructural evidence of stromal/epithelial interactions in the human endometrial cycle

We found ultrastructural evidence of interactions between glandular epithelium and superficial stromal cells of the human endometrium during phases of the menstrual cycle. Four significant changes were observed in the transition from early proliferative (days 5 to 9) to early secretory (days 15 to 19) phases. These changes included: (1) an increase in the number and size of lamina densa disruptions, (2) an increase in the number and size of gap junctions, (3) an increase in the number and complexity of epithelial cell projections that extended through the lamina densa, and (4) an increase in close contacts between stromal and epithelial cells. The complex epithelial cell projections that extended through the lamina densa were in close proximity to stromal cells. These interactions were seen primarily in the early secretory phase. After that time (days 20 to 28) the interactions were less frequent. These morphologic results reveal complex physical interactions between epithelial and stromal cells of the adult endometrium. The interactions reach maximal development during the preimplantation phase of the endometrial cycle.

Induction of nucleolar changes in rat luminal cells by single injection or low-dose infusion of estradiol

The nucleolar area of rat uterine luminal epithelial cells was measured for 41 h after beginning either of two dosage regimens of estradiol (E2): a single injection of 1.0 microgram E2 or a continuous infusion of E2 at a rate of 1.0 microgram/24 h. In response to a single injection of E2, mean nucleolar area was significantly elevated above control levels by 10 h. Nucleolar morphology showed slight changes, but the fibrillar component was always associated with 2-3 fibrillar centers by 10 h. In response to a continuous infusion of E2, mean nucleolar area was elevated by 10 h, reached a maximum by 18 h, and remained relatively constant thereafter. Nucleolar morphology showed significant changes by 10 h; the fibrillar component was commercially denser. Bivariate histograms of nuclear versus nucleolar areas showed a bimodal distribution after both injection and infusion, suggesting that two size classes of nuclei existed after estrogen stimulation. The results suggest that: 1) a continuous infusion of E2 at a rate of 1.0 microgram/24 h was more effective in inducing larger increases in nucleolar area and transcription than a single injection of 1.0 microgram E2 at time 0; 2) using analysis of nuclear and nucleolar areas two subpopulations of cells were identified; and 3) continuous infusion of E2 produced a steady state of ribosome production and cytoplasmic transport by 18 h.

Analysis of chromatin proteins from human placenta

Low-salt extracts of chromatin from human term placenta have been examined for the presence of the high mobility group (HMG) proteins. Based upon salt-dissociation characteristics, solubilities in trichloroacetic acid and electrophoretic behaviour on sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and non-equilibrium pH gradient gel electrophoresis (NEPHGE), each of the HMG proteins is present, including HMG-1, -2, -E, -14, and -17. A remarkably large amount of HMG-E is present in term human placenta. Additionally, a protein not previously recognized, which we designate HMG-PL, is present in term placenta. Electrophoretic comparison of the HMG proteins from placentae of varying gestational age, using NEPHGE, demonstrates that all of the placental HMG proteins exhibit multiplicity, reminiscent of chicken erythrocyte HMG proteins. Specifically, we found HMG-E to be unaltered in amounts relative to HMG-1 and -2 in placentae varying from 20 to 40 weeks of gestation. HMG-PL, however, is differentially expressed, increasing in amounts as gestation proceeds past 34 weeks. HMG-PL was purified and subjected to amino acid analysis. Its composition supports the notion that HMG-PL is a member of the HMG-1 family.