Nonmedically indicated induction vs expectant treatment in term nulliparous women

OBJECTIVE

The purpose of this study was to compare maternal and neonatal outcomes in nulliparous women with nonmedically indicated inductions at term vs those expectantly treated.

STUDY DESIGN

Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a 3-year period. A low-risk subset of nulliparous women with vertex nonanomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for nonmedically indicated induction within each week were compared with women who did not undergo nonmedically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use, and insurance status.

RESULTS

We found 31,169 women who met our criteria. Neonatal complications were either less frequent with nonmedically indicated induction or no different between groups. Nonmedically indicated induction was associated with less frequent peripartum infections (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16-0.98) at 38 weeks of gestation and less frequent third- and fourth-degree lacerations (OR, 0.60; 95% CI, 0.42-0.86) and less frequent peripartum infections (OR, 0.66; 95% CI, 0.49-0.90) at 39 weeks of gestation. Nonmedically indicated induction was associated with a longer admission-to-delivery time by approximately 3-4 hours and increased odds of cesarean delivery at 38 (OR, 1.50; 95% CI, 1.08-2.08) and 40 weeks (OR, 1.30; 95% CI, 1.15-1.46) of gestation.

CONCLUSION

At 39 weeks of gestation, nonmedically indicated induction is associated with lower maternal and neonatal morbidity than women who are expectantly treated.

HOSPEX in the antipodes

The Australian Army recently adopted the British concept of hospital exercise (HOSPEX) as a means of evaluating the capabilities of its deployable NATO Role 2E hospital, the 2nd General Health Battalion. The Australian approach to HOSPEX differs from the original UK model. This article describes the reasons why the Australian Army needed to adopt the HOSPEX concept, how it was adapted to suit local circumstances and how the concept may evolve to meet the needs of the wider Australian Defence Force and our allies.

Consumer exposures to laser printer-emitted engineered nanoparticles: A case study of life-cycle implications from nano-enabled products

It is well established that printers emit nanoparticles during their operation. To-date, however, the physicochemical and toxicological characterization of "real world" printer-emitted nanoparticles (PEPs) remains incomplete, hampering proper risk assessment efforts. Here, we investigate our earlier hypothesis that engineered nanomaterials (ENMs) are used in toners and ENMs are released during printing (consumer use). Furthermore, we conduct a detailed physicochemical and morphological characterization of PEPs in support of ongoing toxicological assessment. A comprehensive suite of state of the art analytical methods and tools was employed for the physicochemical and morphological characterization of 11 toners widely utilized in printers from major printer manufacturers and their PEPs. We confirmed that a number of ENMs incorporated into toner formulations (e.g. silica, alumina, titania, iron oxide, zinc oxide, copper oxide, cerium oxide, carbon black among others) and released into the air during printing. All evaluated toners contained large amounts of organic carbon (OC, 42-89%), metals/metal oxides (1-33%), and some elemental carbon (EC, 0.33-12%). The PEPs possess a composition similar to that of toner and contained 50-90% OC, 0.001-0.5% EC and 1-3% metals. While the chemistry of the PEPs generally reflected that of their toners, considerable differences are documented indicative of potential transformations taking place during consumer use (printing). We conclude that: (i) Routine incorporation of ENMs in toners classifies them as nano-enabled products (NEPs); (ii) These ENMs become airborne during printing; (iii) The chemistry of PEPs is complex and it reflects that of the toner and paper. This work highlights the importance of understanding life-cycle (LC) nano-EHS implications of NEPs and assessing real world exposures and associated toxicological properties rather than focusing on "raw" materials used in the synthesis of an NEP.

Abstract 5578: Breast cancer cell growth regulatory mechanisms of tamoxifen metabolites

The proliferation of estrogen receptor alpha (ERalpha)-positive breast cancer cells is stimulated by estradiol. Tamoxifen [(Z)-2-[4-(1,2-diphenylbut-1-enyl)phenoxy]-N,N-dimethylethanamine] is the most commonly used endocrine treatment for ERalpha-positive breast cancer in pre- and post-menopausal women. Tamoxifen is metabolized to 4-hydroxytamoxifen and endoxifen. ICI 182780 (Faslodex or Fulvestrant) is a pure antiestrogen targeted to the ERalpha. We investigated the effects of endoxifen and 4-hydroxytamoxifen on ERalpha-positive MCF-7 breast cancer cells using cell growth assay, oncogene expression and polyamine regulatory pathways. Polyamines are ubiquitous cellular components and are essential for cell growth and differentiation. Treatment of cells for 1-5 days with 4 nM estradiol increased cells number, whereas the addition of endoxifen, 4-hydroxytamoxifen or ICI 182780 in combination with estradiol suppressed cell growth in a concentration- and time-dependent manner. Real time quantitative polymerase chain reaction (RT-qPCR) experiments showed that the addition of 4 nM estradiol to MCF-7 cells increased the expression of c-myc, c-fos and Tiff1 genes significantly, while the addition endoxifen, 4-hydroxytamoxifen, or ICI 182780 suppressed estradiol-mediated increase in gene expression. Polyamine biosynthetic enzymes were also affected by tamoxifen metabolites. Estradiol increased the activities of the polyamine biosynthetic enzyme, ornithine decarboxlase (ODC) and S-adenosylmethionine decarboxlase (AdoMetDC), whereas the antiestrogens suppressed ODC and AdoMetDC activities in a concentration- and time-dependent manner. However, these agents had little effect on the activity of the polyamine catabolic enzyme, spermidine/spermine N1-acetyl transferase (SSAT). The change in biosynthetic enzyme activities was reflected in polyamine pools, as decreased putrescine and spermidine levels. There was no significant change in spermine level. These results suggest that the mechanism of action of tamoxifen metabolites involves multiple cell growth regulatory pathways. In addition, endoxifen can act as an antiestrogen and suppress cell growth stimulatory effects of estradiol on ERalpha-positive breast cancer cells in a manner similar to that of ICI 182780.

Note: This abstract was not presented at the meeting.

Citation Format: T. Thomas, Huichen Hsu, PingAr Yang, Mervi T. Hyvonen, Tuomo A. Keinanen. Breast cancer cell growth regulatory mechanisms of tamoxifen metabolites. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5578. doi:10.1158/1538-7445.AM2014-5578

Cost-effectiveness analysis of hip fracture prevention with vitamin D supplementation: a Markov micro-simulation model applied to the French population over 65 years old without previous hip fracture

We performed a cost-effectiveness analysis of four vitamin D supplementation strategies for primary prevention of hip fracture among the elderly population and found that the most cost-effective strategy was screening for vitamin D insufficiency followed by adequate treatment to attain a minimum 25(OH) serum level.

INTRODUCTION

Vitamin D supplementation has a demonstrated ability to reduce the incidence of hip fractures. The efficiency of lifetime supplementation has not yet been assessed in the population over 65 years without previous hip fracture. The objective was to analyze the efficiency of various vitamin D supplementation strategies for that population.

METHODS

A Markov micro-simulation model was built with data extracted from published studies and from the French reimbursement schedule. Four vitamin D supplementation strategies were evaluated on our study population: (1) no treatment, (2) supplementation without any serum level check; (3) supplementation with a serum level check 3 months after initiation and subsequent treatment adaptation; (4) population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level.

RESULTS

"Treat, then check" and "screen and treat" were two cost-effective strategies and dominated "treat without check" with incremental cost-effectiveness ratios of €5,219/quality-adjusted life-years (QALY) and €9,104/QALY, respectively. The acceptability curves showed that over €6,000/QALY, the "screen and treat" strategy had the greatest probability of being cost-effective, and the "no treatment" strategy would never be cost-effective if society were willing to spend over €8,000/QALY. The sensitivity analysis showed that among all parameters varying within realistic ranges, the cost of vitamin D treatment had the greatest effect and yet remained below the WHO cost-effectiveness thresholds.

CONCLUSIONS

Population screening for vitamin D insufficiency followed by treatment based on the vitamin D serum level is the most cost-effective strategy for preventing hip fracture occurrence in the population over 65 years old.

Maintaining a way of life for São Miguel Island (the Azores archipelago, Portugal): an assessment of coastal processes and protection

Traditional hard engineering structures and recently emerging soft engineering alternatives have been employed to protect vulnerable coastlines. Despite negative publicity, they have ensured community survival where socio-economic benefits outweigh adverse impacts. This is especially true for Small Islands (SI) where increasing sea levels and storm intensities threaten already limited land availability. This paper presents coastal vulnerability in São Miguel Island (the Azores SI archipelago) and considers SI issues with regard to coastal land loss. Regional wave statistics using 1998 to 2011 wind record showed: periods ranging from 7 to 13s (circa 83%); wave heights between 1 and 3m (circa 60%); and increasing trends in westerly (p=0.473), easterly (p=0.632) and southeasterly (p=0.932) waves. Sea level analyses between 1978 and 2007 indicated a statistically significant rising trend (2.5 ± 0.4 mm yr(-1); p=0.000), while between 1996 and 2007 it was 3.3 ± 1.5 mm yr(-1) (p=0.025), agreeing with other global sea level studies. Based on 2001 and 2008 population data and using zonal statistics, circa 60% of the Island's population was found to reside within 1 km of the sea and the percentage of total population was linearly correlated with distance from the shoreline (r(2)=99%). Three case studies show hard coastal engineering solutions preserved Azorean coastal lifestyle and had little or no observed negative impacts on their environs. Although hard engineering is likely to remain a valuable and feasible coastal protection option, an inventory of São Miguel's population distribution, surf breaks, bathymetry and coastal erosion rates showed the potential of using multifunctional artificial reefs as a soft engineering solution. These offshore submerged breakwaters offer coastal protection while providing additional benefits such as surfing amenity and beach widening. Consequently, findings of this work can inform other SI communities.

First report of detection and molecular confirmation of Plasmodium ovale from severe malaria cases in central India

OBJECTIVE

We report for the first-time detection of Plasmodium ovale in central India.

METHODS

From 2010, all hospitalised suspected malaria cases at the malaria clinic of the Regional Medical Research Centre for Tribals in Bastar district, central India, were screened. Plasmodium species were identified by microscopy and species-specific nested PCR of 18s rRNA.

RESULTS

Of 256 enrolled cases of confirmed P. falciparum malaria by microscopy, P. ovale infection was detected in three cases (1.2%) by PCR and sequencing. Of these three cases, one had cerebral malaria and another had severe malaria anaemia. In both of these cases, P. ovale infection was mixed with P. falciparum, while in third case the infection was mixed with both P. falciparum and P. vivax. Phylogenetic analysis revealed that these isolates showed closed homology with West African genotypes.

CONCLUSION

All three hospitalised patients were originally residents of remote inaccessible forest villages and never moved out of their residence. This finding also has implications in malaria control and elimination as P. ovale causes relapses. This study highlights the need of molecular diagnosis of malaria species for appropriate treatment and control.

The epidemiology of falling-through-the-ice in Alaska, 1990-2010

BACKGROUND

Climate change has contributed to increasing temperatures, earlier snowmelts and thinning ice packs in the Arctic, where crossing frozen bodies of water is essential for transportation and subsistence living. In some Arctic communities, anecdotal reports indicate a growing belief that falling-through-the-ice (FTI) are increasing. The objective of this study was to describe the morbidity and mortality associated with unintentional FTIs in Alaska.

METHODS

We searched newspaper reports to identify FTI events from 1990 to 2010. We also used data from a trauma registry, occupational health and law enforcement registries and vital statistics to supplement the newspaper reports. Morbidity and mortality rates were calculated for Alaska Native (AN) people and all Alaskans.

RESULTS

During the 21-year period, we identified 307 events, affecting at least 449 people. Events ranged from no morbidity to fatalities of five people. More than half of the events involved transportation by snow machine. Mortality rates were markedly higher for AN people than that for all Alaskans.

CONCLUSIONS

We provide a numeric estimate of the importance of FTI events in Alaska. FTIs may represent an adverse health outcome related to climate changes in the Arctic, and may be particularly critical for vulnerable populations such as AN people.

High bone turnover persisting after vitamin D repletion: beware of calcium deficiency

Treatment of vitamin D deficiency with vitamin D is a common procedure when taking care of elderly patients, calcium supplementation being added only when calcium dietary intake is insufficient. Here, we report the case of a 58-year-old female who was referred to our unit because of suspicion of Paget's disease of the skull, based on elevated serum alkaline phosphatase and high skull methylene diphosphonate-technetium uptake. She had been prescribed cholecalciferol (100,000 IU/month) and calcium salts for the past 7 months after discovery of severe vitamin D deficiency by her primary care physician. No specific skull bone lesions were observed on both X-ray and computerized tomography. Serum calcium, phosphate and 25(OH) vitamin D levels were normal, while serum C-terminal cross-linked telopeptide, bone alkaline phosphatase and calcitriol were high and daily urinary calcium excretion was low. We found that she had not been compliant with the calcium prescription while vitamin D had been thoroughly taken. We suspected osteomalacia due to calcium deficiency. Both skull uptake and biological abnormalities normalised in few months after adding calcium supplementation to the vitamin D treatment, and spine bone mineral density increased by 9.5 % after 14 months of full treatment. The present case illustrates the necessity for adequate calcium intake during vitamin D repletion to normalise bone mineralisation and turnover and maintain the skeletal integrity.

Sleep and birthweight predict visceral adiposity in overweight/obese children

BACKGROUND

Visceral adiposity poses significant consequences for long-term health and it is important to identify methods that can be used to prevent fat deposition in visceral adipose tissue.

OBJECTIVE

To identify the factors contributing to differential fat distribution in overweight/obese children.

METHODS

Demographic, dietary and lifestyle factors potentially associated with increased visceral adipose tissue in overweight and obese South-Indian children aged 3 to 16 years. The diagnosis of visceral obesity was based on the waist-to-height ratio (WHtR) cut-off value of 0.5.

RESULTS

Exposure variables with statistically different distributions in the two WHtR categories, when examined by Mann-Whitney and chi-square tests, were used to develop a binary logistic regression model of visceral adiposity. Increased birthweight and higher sleep duration were significant predictors of having a healthy WHtR, with odds ratios of 1.30 and 1.26 respectively.

CONCLUSIONS

Early programming effects associated with low birthweight and current sleep deprivation could promote the storage of excess fat as visceral adipose tissue in overweight and obese children.

VO2 max in an Indian population: a study to understand the role of factors determining VO2 max

VO2 max is the maximum amount of oxygen a person can consume and the value does not change despite an increase in workload. There is lack of data evaluating the impact of factors, which could affect VO2 max measurement, particularly in Indian population. The objectives of the present study were (i) to estimate VO2 max in a young healthy Indian population and to compare it with available prediction equations for Indian population (ii) to correlate time to achieve VO2 max with the relative VO2 max (iii) to assess the factors affecting the time to achieve VO2 max measurement (body composition and physical activity level). Twenty healthy adult males (18-30 years) underwent detailed anthropometry, physical activity level and modified Bruce protocol for VO2 max assessment. Breath by breath VO2, VCO2, oxygen saturation, heart rate, blood pressure were measured continuously and following exercise protocol. There was an internal validity between the estimated VO2 max and the maximum heart rate (MHR) (r = 0.51, P < 0.05). Respiratory rate and tidal volume significantly correlated with VO2 max P < 0.01). Linear regression analysis indicated physical activity level (PAL) was a strong predictor of time to reach VO2 max. Out of the 3 prediction equations computed to estimate VO2 max, 2 equations significantly overestimated VO2 max. In Conclusion, physical activity level emerged to be a strong predictor of time to VO2 max. Time to achieve VO2 max is an important factor to be considered when determining VO2 max. There was an overestimation in the VO2 max values derived from predicted equations.

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)--quality of life during the first 4 months after fracture

The quality of life during the first 4 months after fracture was estimated in 2,808 fractured patients from 11 countries. Analysis showed that there were significant differences in the quality of life (QoL) loss between countries. Other factors such as QoL prior fracture and hospitalisation also had a significant impact on the QoL loss.

INTRODUCTION

The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) was initiated in 2007 with the objective of estimating costs and quality of life related to fractures in several countries worldwide. The ICUROS is ongoing and enrols patients in 11 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, UK and the USA). The objective of this paper is to outline the study design of ICUROS and present results regarding the QoL (measured using the EQ-5D) during the first 4 months after fracture based on the patients that have been thus far enrolled ICUROS.

METHODS

ICUROS uses a prospective study design where data (costs and quality of life) are collected in four phases over 18 months after fracture. All countries use the same core case report forms. Quality of life was collected using the EQ-5D instrument and a time trade-off questionnaire.

RESULTS

The total sample for the analysis was 2,808 patients (1,273 hip, 987 distal forearm and 548 vertebral fracture). For all fracture types and countries, the QoL was reduced significantly after fracture compared to pre-fracture QoL. A regression analysis showed that there were significant differences in the QoL loss between countries. Also, a higher level of QoL prior to the fracture significantly increased the QoL loss and patients who were hospitalised for their fracture also had a significantly higher loss compared to those who were not.

CONCLUSIONS

The findings in this study indicate that there appear to be important variations in the QoL decrements related to fracture between countries.

Effect of oral monthly ibandronate on bone microarchitecture in women with osteopenia-a randomized placebo-controlled trial

We have examined the effect of oral monthly ibandronate on distal radius and tibia microarchitecture with high-resolution peripheral quantitative tomography compared with placebo, in women with osteopenia, and found that ibandronate did not significantly affect trabecular bone but improved cortical density and thickness at the tibia.

METHODS

We have examined the effect of ibandronate on bone microarchitecture with peripheral high-resolution quantitative computed tomography (HR-pQCT) in a randomized placebo-controlled trial among 148 women with osteopenia. Patients received either oral 150 mg monthly ibandronate or placebo over 24 months. Bone microarchitecture was assessed at baseline, 6, 12, and 24 months, using HR-pQCT at the distal radius and tibia; areal bone mineral density (aBMD) was measured with DXA at the spine, hip, and radius.

RESULTS

At 12 months, there was no significant difference in trabecular bone volume at the radius (the primary end point) between women on ibandronate (10.8 ± 2.5%) and placebo (10.5 ± 2.9%), p = 0.25. There was no significant difference in other radius trabecular and cortical microarchitecture parameters at 12 and 24 months. In contrast, at the tibia, cortical vBMD in the ibandronate group was significantly greater than in the placebo group at 6, 12, and 24 months, with better cortical thickness at 6, 12, and 24 months. With ibandronate, aBMD was significantly increased at the hip and spine at 12 and 24 months but at the radius was significantly superior to placebo only at 24 months. Most of the adverse events related to ibandronate were expected with bisphosphonate use, and none of them were serious.

CONCLUSION

We conclude that 12 months of treatment with ibandronate in women with osteopenia did not affect trabecular bone microarchitecture, but improved cortical vBMD at the tibia at 12 and 24 months, and preserved cortical thickness at the tibia.

Oral bisphosphonates reduce the risk of clinical fractures in glucocorticoid-induced osteoporosis in clinical practice

This study aims to estimate bisphosphonate effectiveness by comparing fracture incidence over time on therapy in glucocorticoid-induced osteoporosis (GIO). From this observational study, alendronate and risedronate decreased clinical vertebral and nonvertebral fractures over time. The effectiveness of each bisphosphonate is consistent with their efficacies demonstrated on surrogate markers in randomized controlled trials (RCTs).

INTRODUCTION

This study aims to estimate bisphosphonate effectiveness by comparing fracture incidence over time on therapy with fracture incidence during a short period after starting a therapy.

METHODS

The study population was a subgroup of a larger cohort study comprising two cohorts of women aged ≥65 years, prescribed with alendronate or risedronate. Within the two study cohorts, 11,007 women were identified as having received glucocorticoids. Within each cohort, the baseline incidence of clinical fractures at nonvertebral and vertebral sites was defined by the initial 3-month period after starting therapy. Relative to these baseline data, we then compared the fracture incidence during the subsequent 12 months on therapy.

RESULTS

The baseline incidence of clinical nonvertebral and vertebral fractures was similar in the alendronate cohort (5.22 and 5.79/100 person-years, respectively) and in the risedronate cohort (5.51 and 5.68/100 person-years, respectively). Relative to the baseline incidence, fracture incidence was significantly lower in the subsequent 12 months in both cohorts of alendronate (33 % lower at nonvertebral sites and 59 % at vertebral sites) and risedronate (28 % lower at nonvertebral sites and 54 % at vertebral sites).

CONCLUSION

From this observational study not designed to compare drugs, both alendronate and risedronate decreased clinical vertebral and nonvertebral fractures over time. The reductions observed in fracture incidence, within each cohort, suggest that the effectiveness of each bisphosphonate in clinical practice is consistent with their efficacies demonstrated on surrogate markers in randomized controlled trials.

South pole bang-time diagnostic on the National Ignition Facility (invited)

The south pole bang-time diagnostic views National Ignition Facility (NIF) implosions through the lower Hohlraum laser entrance hole to measure the time of peak x-ray emission (peak compression) in indirect-drive implosions. Five chemical-vapor-deposition diamond photoconductive detectors with different filtrations and sensitivities record the time-varying x rays emitted by the target. Wavelength selecting highly oriented pyrolytic graphite crystal mirror monochromators increase the x-ray signal-to-background ratio by filtering for 11-keV emission. Diagnostic timing and the in situ temporal instrument response function are determined from laser impulse shots on the NIF. After signal deconvolution and background removal, the bang time is determined to 45-ps accuracy. The x-ray "yield" (mJ∕sr∕keV at 11 keV) is determined from the time integral of the corrected peak signal.