Household air pollution and personal exposure to nitrated and oxygenated polycyclic aromatics (PAHs) in rural households: Influence of household cooking energies

Residential solid fuels are widely consumed in rural China, contributing to severe household air pollution for many products of incomplete combustion, such as polycyclic aromatic hydrocarbons (PAHs) and their polar derivatives. In this study, concentrations of nitrated and oxygenated PAH derivatives (nPAHs and oPAHs) for household and personal air were measured and analyzed for influencing factors like smoking and cooking energy type. Concentrations of nPAHs and oPAHs in kitchens were higher than those in living rooms and in outdoor air. Exposure levels measured by personal samplers were lower than levels in indoor air, but higher than outdoor air levels. With increasing molecular weight, individual compounds tended to be more commonly partitioned to particulate matter (PM); moreover, higher molecular weight nPAHs and oPAHs were preferentially found in finer particles, suggesting a potential for increased health risks. Smoking behavior raised the concentrations of nPAHs and oPAHs in personal air significantly. People who cooked food also had higher personal exposures. Cooking and smoking have a significant interaction effect on personal exposure. Concentrations in kitchens and personal exposure to nPAHs and oPAHs for households using wood and peat were significantly higher than for those using electricity and liquid petroleum gas (LPG).

The natural history of endometrial polyps

STUDY QUESTION

What is the natural history of endometrial polyps in women who are managed expectantly?

SUMMARY ANSWER

The growth rates of expectantly managed polyps vary considerably and cannot be accurately predicted.

WHAT IS KNOWN ALREADY

The majority of polyps detected on ultrasound are treated surgically, and therefore little is known about their natural history. Some polyps have been reported to regress spontaneously without the need for treatment; however, the factors predictive of regression are unknown.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study conducted at the Department of Gynaecology, University College London Hospitals. We searched our ultrasound clinic database between July 1997 and September 2015, to identify women aged 18 years or older with endometrial polyps that were managed expectantly for ≥6 months. All women attended for a minimum of two ultrasound scans.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A single expert operator performed all ultrasound scans. Those with <6-month follow-up and those who were taking hormonal contraception, HRT or tamoxifen were excluded from the study. The mean diameter of each polyp was calculated from the measurements in three perpendicular planes. The polyp growth rate was expressed as annual percentage change in the mean diameter. Non-parametric tests and the Fisher's exact test were used to compare differences in polyp mean diameters and growth rates between women of different demographic characteristics. To correct for multiple significance testing, we used the Bonferroni method, giving the level of probability at which findings were considered significant as P < 0.0029 (as 17 tests were undertaken).

MAIN RESULTS AND THE ROLE OF CHANCE

We included 112 women with endometrial polyps, which were expectantly managed over a median period of 22.5 months (range, 6-136). The annual endometrial polyp growth rate varied with a median of 1.0% (interquartile range, -6.5 to 14.3). There was no association between women's demographic characteristics or polyps' morphology and their growth rates. Eleven out of 75 (15% (95% CI, 6.9%-23.1%)) women who initially did not have abnormal uterine bleeding subsequently developed abnormal bleeding during the follow-up period. Polyp growth rate was not associated with the subsequent development of abnormal uterine bleeding (P = 0.397). Seven out of 112 (6.3% (95% CI, 1.8%-10.8%)) women had complete regression of their polyps without treatment during a median follow-up period of 28 months (range, 9-56). Spontaneous regression appeared to occur more frequently in premenopausal women (P = 0.016) and in those who presented with abnormal uterine bleeding at diagnosis (P = 0.004); however, the differences did not reach statistical significance after correction for multiple comparisons.

LIMITATIONS, REASONS FOR CAUTION

This study was retrospective and therefore may be prone to selection and information biases. The lack of histological confirmation on all ultrasound diagnoses may also be considered as a limitation.

WIDER IMPLICATIONS OF THE FINDINGS

Women should be advised that the growth pattern of an individual polyp cannot be accurately predicted; however, a small proportion of polyps do regress spontaneously. There was no correlation between polyps' growth rate and the subsequent development of abnormal uterine bleeding. In view of that, routine monitoring of asymptomatic polyps by ultrasound is not helpful and encouraging women to report clinical symptoms is more useful in deciding whether treatment is required. In contrast to previous studies, we found that polyps may regress more frequently in premenopausal women and in those who presented with abnormal uterine bleeding; a larger sample size would give us greater power to detect a difference in these subgroups of women.

STUDY FUNDING/COMPETING INTERESTS

No study funding was received and no competing interests are present.

TRIAL REGISTRATION NUMBER

N/A.

Waist-to-height ratio, body mass index and waist circumference for screening paediatric cardio-metabolic risk factors: a meta-analysis

Waist-to-height ratio (WHtR) is superior to body mass index and waist circumference for measuring adult cardio-metabolic risk factors. However, there is no meta-analysis to evaluate its discriminatory power in children and adolescents. A meta-analysis was conducted using multiple databases, including Embase and Medline. Studies were included that utilized receiver-operating characteristics curve analysis and published area under the receiver-operating characteristics curves (AUC) for adiposity indicators with hyperglycaemia, elevated blood pressure, dyslipidemia, metabolic syndrome and other cardio-metabolic outcomes. Thirty-four studies met the inclusion criteria. AUC values were extracted and pooled using a random-effects model and were weighted using the inverse variance method. The mean AUC values for each index were greater than 0.6 for most outcomes including hypertension. The values were the highest when screening for metabolic syndrome (AUC > 0.8). WHtR did not have significantly better screening power than other two indexes in most outcomes, except for elevated triglycerides when compared with body mass index and high metabolic risk score when compared with waist circumference. Although not being superior in discriminatory power, WHtR is convenient in terms of measurement and interpretation, which is advantageous in practice and allows for the quick identification of children with cardio-metabolic risk factors at an early age.

Effect of Tdap when administered before, with or after the 13-valent pneumococcal conjugate vaccine (coadministered with the quadrivalent meningococcal conjugate vaccine) in adults: A randomised controlled trial

Sequential or co-administration of vaccines has potential to alter the immune response to any of the antigens. Existing literature suggests that prior immunisation of tetanus/diphtheria-containing vaccines can either enhance or suppress immune response to conjugate pneumococcal or meningococcal vaccines. We examined this interaction among adult Australian travellers before attending the Hajj pilgrimage 2014. We also investigated tolerability of these vaccines separately and concomitantly. We randomly assigned each participant to one of three vaccination schedules. Group A received adult tetanus, diphtheria and acellular pertussis vaccine (Tdap) 3-4weeks before receiving CRM197-conjugated 13-valent pneumococcal vaccine (PCV13) and CRM197-conjugated quadrivalent meningococcal vaccine (MCV4). Group B received all three vaccines on one day. Group C received PCV13 and MCV4 3-4weeks before Tdap. Blood samples collected at baseline, each vaccination visit and 3-4weeks after vaccination were tested using the pneumococcal opsonophagocytic assay (OPA) and by ELISA for diphtheria and tetanus antibodies. Funding for meningococcal serology was not available. Participants completed symptom diaries after each vaccination. A total of 111 participants aged 18-64 (median 40) years were recruited. No statistically significant difference was detected across the three groups in achieving OPA titre ⩾1:8 post vaccination. However, compared to other groups, Group A had a statistically significant lower number of subjects achieving ⩾4-fold rise in serotype 3, and also significantly lower geometric mean titres (GMTs) to six (of 13) pneumococcal serotypes (3, 5, 18C, 4, 19A and 9V). Group C (given prior PCV13 and MVC4) had statistically significant higher pre-Tdap geometric mean concentration (GMC) of anti-diphtheria IgG; however, there was no difference across the three groups following Tdap. Anti-tetanus IgG GMCs were similar across the groups before and after Tdap. No serious adverse events were reported. In conclusion, Tdap vaccination 3-4weeks before concomitant administration of PCV13 and MCV4 significantly reduced the antibody response to six of the 13 pneumococcal serotypes in adults. The trial is registered at the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000536763.

Attitudes about Organ and Tissue Donation among the General Public and Blood Donors in Hong Kong

Context

The cadaveric organ and tissue donation rate in Hong Kong is not satisfactory; 1 million blood donors are registered and more than 300 000 are active. However, the current attitudes toward organ and tissue donation in the general public and blood donors of Hong Kong are unknown.

Methods

Random general public (n = 1018) and blood donors (n = 1227) of Chinese origin, with age ranging from 16 to 60 years, were interviewed using a standard verified questionnaire that examines attitudes and knowledge of organ and tissue donation.

Results

The mean age of the general public and blood donors were 32.6 and 28.9 years, respectively. Of the general public, 44.4% were men and among blood donors, 60% were men. About 56% of both groups thought that organ donation is an obligation of citizens. Blood donors were more aware than the general public about the types of organs that can be donated. When compared with the general public, a significantly higher percentage of blood donors were willing to donate their organs (81% vs 53%), had heard about organ donation cards (98.3% vs 89.5%), and had signed the cards (49.9% vs 22.6%). About 70% of both groups who had signed a card were carrying it. Thirty-nine percent of the general public and 17% of blood donors had not decided whether they would donate. For blood donors, 49.7% were willing to donate their relatives' organs, compared with 41.8% of the general public. Most individuals in both groups would not object to their relatives' decision to donate. About two thirds of individuals in both groups disagreed with the concept of an opt-out law, though only 20% of the general public and 14.4% of blood donors would refuse donation if an opt-out law were in practice.

Conclusions

This study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an organ donation card than the general public. However, a substantial proportion of blood donors have not signed a donor card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

Opportunities for improvement in care among women with severe maternal morbidity

BACKGROUND

Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care.

OBJECTIVE

The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care.

STUDY DESIGN

We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition.

RESULTS

There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors.

CONCLUSION

We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.

FGF2 from Marrow Microenvironment Promotes Resistance to FLT3 Inhibitors in Acute Myeloid Leukemia

Potent FLT3 inhibitors, such as quizartinib (AC220), have shown promise in treating acute myeloid leukemia (AML) containing FLT3 internal tandem duplication (ITD) mutations. However, responses are not durable and resistance develops within months. In this study, we outline a two-step model of resistance whereby extrinsic microenvironmental proteins FLT3 ligand (FL) and fibroblast growth factor 2 (FGF2) protect FLT3-ITD+ MOLM14 cells from AC220, providing time for subsequent accumulation of ligand-independent resistance mechanisms. FL directly attenuated AC220 inhibition of FLT3, consistent with previous reports. Conversely, FGF2 promoted resistance through activation of FGFR1 and downstream MAPK effectors; these resistant cells responded synergistically to combinatorial inhibition of FGFR1 and FLT3. Removing FL or FGF2 from ligand-dependent resistant cultures transiently restored sensitivity to AC220, but accelerated acquisition of secondary resistance via reactivation of FLT3 and RAS/MAPK signaling. FLT3-ITD AML patients treated with AC220 developed increased FGF2 expression in marrow stromal cells, which peaked prior to overt clinical relapse and detection of resistance mutations. Overall, these results support a strategy of early combination therapy to target early survival signals from the bone marrow microenvironment, in particular FGF2, to improve the depth of response in FLT3-ITD AML. Cancer Res; 76(22); 6471-82. ©2016 AACR.

Abstract 1631: FGF2 activation of FGFR1 in head and neck squamous cell carcinoma is associated with more invasive disease and can be attenuated by FGFR inhibition

Introduction. Head and neck squamous cell carcinomas (HNSCCs) account for nearly 600,000 deaths worldwide annually and have limited treatment options. Approximately 20% of HNSCCs harbor amplifications of fibroblast growth factor receptor 1 (FGFR1) on chromosome 8p, however FGFR1 amplification by itself does not predict clinical response to FGFR inhibitors. We hypothesized that FGF2, or basic FGF, ligand expression is a better marker of FGFR activation and predictor of response to FGFR inhibitors.

Results. A tissue micro array (TMA) of HNSCC patient biopsies was stained and quantitated for FGF2 expression by Aperio ImageScope software. FGF2 was significantly increased in recurrent tissue samples (p = 0.04). We examined a number of immortalized HNSCC cell lines and found that overexpression of both FGF2 and FGFR1 predicted response to the selective FGFR inhibitor PD173074. FGFR inhibition did not cause apoptosis, but rather induced a G0/G1 arrest and growth inhibition. FGFR inhibition also induced a change in cell morphology, with a significant increase in cell size and adherence. The expression of epithelial-to-mesenchymal transition (EMT) proteins was examined and FGF2-FGFR1 activation was associated with a more mesenchymal phenotype. Accordingly, FGFR inhibition reversed invasiveness as measured using the Incucyte WoundMaker scratch assay, suggesting that HNSCCs with FGF2-FGFR1 activation have more metastatic potential. Invasiveness of these cells in vivo was confirmed using orthotopic injection into the buccal pad of NSG mice. Once primary tumors reached 0.8 cm in size, mice were sacrificed and buccal mucosa, lung, liver, and neck tissue were examined post-mortem. All of the injected animals developed local invasion, and distant metastases in the lungs. 5/7 mice also had metastases in the liver and this model is being used to test the ability of FGFR inhibition to prevent metastasis.

The mechanism of autocrine FGF2-FGFR1 activation was further explored and FGF2 was found to be secreted in association with extracellular vesicles (ECVs). Interestingly, inhibition of FGFR reduced secretion of ECVs and FGF2, providing a novel approach to target autocrine and paracrine FGFR1 activation within the tumor. We further tested a number of small molecule inhibitors in combination with PD173074 to look for synergistic combinations of kinase inhibitors and found significant synergy between EGFR and FGFR inhibitors suggesting this combination may be most effective in patients with HNSCC.

Conclusions. Increased FGF2 in HNSCC patient samples is correlated with recurrent disease. FGF2-FGFR1 activation increases invasiveness through activation of EMT genes both in vitro, and in an orthotopic model. Inhibition of FGF2-FGFR1 reversed the invasive phenotype in vitro and may be an effective therapeutic strategy to reduce metastases in HNSCC patients.

Citation Format: Isabel A. English, Jacqueline Martinez, Edward El Rassi, Mark Schmidt, Ellen Langer, Sophia Bornstein, John Gleysteen, Melissa Wong, Brian Druker, Elie Traer. FGF2 activation of FGFR1 in head and neck squamous cell carcinoma is associated with more invasive disease and can be attenuated by FGFR inhibition. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1631.

Imaging Appearance of SMARCB1 (INI1)-Deficient Sinonasal Carcinoma: A Newly Described Sinonasal Malignancy

SMARCB1 (INI1)-deficient sinonasal carcinomas were first described in 2014, and this series of 17 cases represents the first imaging description. This tumor is part of a larger group of SMARCB1-deficient neoplasms, characterized by aggressive behavior and a rhabdoid cytopathologic appearance, that affect multiple anatomic sites. Clinical and imaging features overlap considerably with other aggressive sinonasal malignancies such as sinonasal undifferentiated carcinoma, which represents a common initial pathologic diagnosis in this entity. SMARCB1 (INI1)-deficient sinonasal tumors occurred most frequently in the nasoethmoidal region with invasion of the adjacent orbit and anterior cranial fossa. Avid contrast enhancement, intermediate to low T2 signal, and FDG avidity were frequent imaging features. Approximately half of the lesions demonstrated calcification, some with an unusual "hair on end" appearance, suggesting aggressive periosteal reaction.

Verrucous carcinoma – an embarrassing problem?

Human papillomaviruses (HPVs) types 6 and 11 are usually associated with benign genital condylomata, but here we describe an extreme case of verrucous carcinoma associated with HPV 6 in a patient too embarrassed to seek early medical advice.