Variation in cervical cancer screening test utilization and results in a United States-based program

BACKGROUND

Little is known about cervical cancer screening strategy utilization (cytology alone, cytology plus high-risk human papillomavirus [HPV] testing [cotesting], primary HPV testing) and test results in the United States.

METHODS

Data from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program were analyzed for 199,578 persons aged 21-65 years screened from 2019 to 2020. Screening test utilization and results were stratified by demographic characteristics and geographic region. Age-standardized pooled HPV test positivity and genotyping test positivity were estimated within cytology result categories.

RESULTS

Primary HPV testing was performed in 592 persons (0.3%). Among the remaining 176,290 persons aged 30-65 years, cotesting was utilized in 72.1% (95% confidence interval [CI] 71.9-72.3%), and cytology alone was utilized in 27.9% (95% CI 27.7-28.1%). Utilization of cytology alone varied by geographic region, ranging from 18.3% (95% CI 17.4-19.1%) to 49.0% (95% CI 48.4-49.6%). HPV genotyping test utilization among those with positive pooled HPV test results was 33.9%. In persons aged ≥30 years, variations in age-adjusted test results by region were observed for pooled HPV-positive test results and for HPV genotyping-positive test results.

CONCLUSIONS

Cervical cancer screening strategy utilization and test results vary substantially by geographic region within a national screening program. Variation in utilization may be due to regional differences in screening test availability or the preferences of healthcare systems, screened persons and/or clinicians. Test result variations may reflect differing risk factors for HPV infections by geographic region.

Differentiating multi-MeV, multi-ion spectra with CR-39 solid-state nuclear track detectors

The development of high intensity petawatt lasers has created new possibilities for ion acceleration and nuclear fusion using solid targets. In such laser-matter interaction, multiple ion species are accelerated with broad spectra up to hundreds of MeV. To measure ion yields and for species identification, CR-39 solid-state nuclear track detectors are frequently used. However, these detectors are limited in their applicability for multi-ion spectra differentiation as standard image recognition algorithms can lead to a misinterpretation of data, there is no unique relation between track diameter and particle energy, and there are overlapping pit diameter relationships for multiple particle species. In this report, we address these issues by first developing an algorithm to overcome user bias during image processing. Second, we use calibration of the detector response for protons, carbon and helium ions (alpha particles) from 0.1 to above 10 MeV and measurements of statistical energy loss fluctuations in a forward-fitting procedure utilizing multiple, differently filtered CR-39, altogether enabling high-sensitivity, multi-species particle spectroscopy. To validate this capability, we show that inferred CR-39 spectra match Thomson parabola ion spectrometer data from the same experiment. Filtered CR-39 spectrometers were used to detect, within a background of ~ 2 × 1011 sr-1 J-1 protons and carbons, (1.3 ± 0.7) × 108 sr-1 J-1 alpha particles from laser-driven proton-boron fusion reactions.

Accelerating Cervical Cancer Screening With Human Papillomavirus Genotyping

INTRODUCTION

Selective utilization of human papillomavirus (HPV) genotyping in cervical cancer screening can accelerate clinical management, leading to earlier identification and treatment of precancerous lesions and cancer. Specifically, immediate colposcopy (instead of 1-year return) is recommended in persons with normal cytology and HPV genotypes 16 and/or 18, and expedited treatment (instead of colposcopy) is recommended in persons with high-grade squamous intraepithelial lesion (HSIL) cytology and HPV genotype 16. The effects of implementing HPV testing and genotyping into a screening program are largely unknown.

METHODS

Average-risk persons aged 30-65 years screened for cervical cancer in the National Breast and Cervical Cancer Early Detection Program from 2019 to 2020 were included (N=104,991). Percentage HPV genotyping test positivity was estimated within cytology result categories. Analyses were performed in 2022.

RESULTS

The most common abnormality was positive high-risk HPV testing with normal cytology, representing 40.1% (7,155/17,832) of all abnormal test result categories; HSIL cytology represented 3.0% (530/17,832) of all abnormal test result categories. In high-risk HPV‒positive persons with normal or high-grade cytology, HPV genotyping could accelerate management (immediate colposcopy and expedited treatment) in 5.4% of all persons with abnormal screening test results; if HPV genotyping had been performed in all high-risk HPV‒positive persons with normal or HSIL cytology, approximately 13.1% could have accelerated management.

CONCLUSIONS

HPV genotyping in human papillomavirus‒positive persons with normal or HSIL cytology could accelerate management in a sizable percentage of persons with abnormal test results and may be particularly useful in populations with challenges adhering to longitudinal follow-up.

Geographic Examination of COVID-19 Test Percent Positivity and Proportional Change in Cancer Screening Volume, National Breast and Cervical Cancer Early Detection Program

Introduction

In 2020, the COVID-19 pandemic led to significant declines in cancer screening, including among women served by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This study examined the spatial association between state-based COVID-19 test percent positivity and proportional change in NBCCEDP screening volume.

Methods

Using the COVID-19 Diagnostic Laboratory Testing dataset, we calculated state-based monthly COVID-19 test percent positivity from July through December 2020 and categorized rates into low, medium, and high groups. We used data from 48 NBCCEDP state awardees to calculate the state-based monthly proportional change in screening volume and compared data for July–December 2020 with the previous 5-year average for those months. We categorized changes in screening volume into large decrease, medium decrease, and minimal change and created maps of the associations between variable subgroups by using bivariate mapping in QGIS.

Results

Bivariate relationships between COVID-19 test percent positivity and proportional change in cancer screening volume varied over time and geography. In 5 of 6 months, 4 states had high COVID-19 test percent positivity and minimal change in breast or cervical cancer screening volume; 2 states had high COVID-19 test percent positivity and minimal change in breast and cervical cancer screening volume.

Conclusion

Some states maintained pre–COVID-19 screening volumes despite high COVID-19 test percent positivity. Follow-up research will be conducted to determine how these states differ from those with consistent decreases in screening volume and identify factors that may have contributed to differences. This information could be useful for planning to maximize NBCCEDP awardees’ ability to maintain screening volume during future public health emergencies.

Relation of Mild Traumatic Brain Injury history to abnormalities on a preliminary Neuroendocrine screen; A multicenter LIMBIC-CENC analysis

PRIMARY OBJECTIVES

Determine if an abnormal preliminary neuroendocrine disorder (NED) blood test screen is associated with mild TBI (mTBI) history or post-concussiveclinical features.

RESEARCH DESIGN

Observational.

METHODS

Among 1,520 participants with military combatexposure, we measured randomly timed serum levels of insulin-likegrowth factor-1, thyroid stimulating hormone (TSH), and total testosterone as a preliminary NED screen. Using multivariable models, we analyzed relation of screen results in mTBI group membership and post-concussiveclinical features (fatigue, depression, cognitive symptoms, executive function, processing speed).

RESULTS

None of the mTBI positive groups, including repetitive (≥3 mTBI) and blast-related,differed from the non-TBIcontrols on rates of abnormal lab screen or rates of growth hormone deficiency (GHD), hypothyroidism or male hypogonadism in treatment records. Lab screen findings were also not associated with any clinical feature.

CONCLUSIONS

This study shows no evidence that remote mTBI(s) or implicated post-concussiveclinical features are linked to GHD, hypothyroidism or male hypogonadism. Large case-controlstudies incorporating more definitive neuroendocrine disorder NED testing (TSH plus thyroxine, early morning testosterone, LH, FSH, prolactin and GH provocative testing) are needed to determine whether mTBI(s) alone elevate one's risk for chronic NED and how best to select patients for comprehensive testing.

An update on the US adult thalassaemia population: a report from the CDC thalassaemia treatment centres

Thalassaemia is caused by genetic globin defects leading to anaemia, transfusion-dependence and comorbidities. Reduced survival and systemic organ disease affect transfusion-dependent thalassaemia major and thalassaemia intermedia. Recent improvements in clinical management have reduced thalassaemia mortality. The therapeutic landscape of thalassaemia may soon include gene therapies as functional cures. An analysis of the adult US thalassaemia population has not been performed since the Thalassemia Clinical Research Network cohort study from 2000 to 2006. The Centers for Disease Control and Prevention supported US thalassaemia treatment centres (TTCs) to compile longitudinal information on individuals with thalassaemia. This dataset provided an opportunity to evaluate iron balance, chelation, comorbidities and demographics of adults with thalassaemia receiving care at TTCs. Two adult cohorts were compared: those over 40 years old (n = 75) and younger adults ages 18-39 (n = 201). The older adult cohort was characterized by higher numbers of iron-related comorbidities and transfusion-related complications. By contrast, younger adults had excess hepatic and cardiac iron and were receiving combination chelation therapy. The ethnic composition of the younger cohort was predominantly of Asian origin, reflecting the demographics of immigration. These findings demonstrate that comprehensive care and periodic surveys are needed to ensure optimal health and access to emerging therapies.

Risk of cervical precancer and cancer among uninsured and underserved women from 2009 to 2017

BACKGROUND

New guidelines for managing cervical precancer among women in the United States use risk directly to guide clinical actions for individuals who are being screened. These risk-based management guidelines have previously only been based on risks from a large integrated healthcare system. We present here data representative of women of low income without continuous insurance coverage to inform the 2019 guidelines and ensure applicability.

OBJECTIVE

We examined the risks of high-grade precancer after human papillomavirus and cytology tests in underserved women and assessed the applicability of the 2019 guidelines to this population.

STUDY DESIGN

We examined cervical cancer screening and follow-up data among 363,546 women enrolled in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program from 2009 to 2017. We estimated the immediate (prevalent) risks of cervical intraepithelial lesion grade 3 or cancer by using prevalence-incidence mixture models. Risks were estimated for each combination of human papillomavirus and cytology result and were stratified by screening history. We compared these risks with published estimates used in new risk-based management guidelines.

RESULTS

Women who were up-to-date with their screening, defined as being screened with cytology within the past 5 years, had immediate risks of cervical intraepithelial neoplasia grade 3 or higher similar to that of women at Kaiser Permanente Northern California, whose data were used to develop the management guidelines. However, women in the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program had greater immediate risks if they were never screened or not up-to-date with their screening.

CONCLUSION

New cervical risk-based management guidelines are applicable for underinsured and uninsured women with a low income in the United States who are up-to-date with their screening. The increased risk observed here among women who received human papillomavirus-positive, high-grade cytology results, who were never screened, or who were not up-to-date with their cervical cancer screening, led to a recommendation in the management guidelines for immediate treatment among these women.

Are uninsured women in a national screening program having longer intervals between cervical cancer screening tests?

With increased understanding of the natural history of cervical cancer, cervical cancer screening recommendations have evolved (Schiffman & Wentzensen, 2013). As research better quantified the balance of benefits and harms of screening, new recommendations called for longer intervals between screening tests. Adherence to longer screening intervals detects similar numbers of abnormalities and decreases harms associated with overscreening/overtreatment. In this descriptive study, we examined the cervical cancer screening intervals from 2010 to 2018 in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). There were 1,397,899 women aged 21-64 who were screened for cervical cancer from 2010 to 2018 and 556,743 rescreenings of average risk women were performed. The median cervical screening interval increased from 2.02 years in 2010 to 3.88 years in 2018. Providers serving uninsured women in a national screening program are following the recommendations of longer intervals between cervical cancer screenings.

0046 Diffusion Tensor Imaging Evidence of Hypothalamic Injury in Traumatic Brain Injury Warfighters with Sleep Dysfunction

Introduction

While sleep disorders occur in 40–70% of chronic traumatic brain injury (TBI) patients, the pathophysiology remains unknown. Increasingly, DTI has been used to evaluate gray matter structures, but no prior studies have evaluated hypothalamic regions in TBI. We hypothesized that TBI patients with poor sleep quality by questionnaire and/or polysomnography (PSG) may have structural injury to hypothalamic sleep circuitry and that this may be detectable by diffusion magnetic resonance imaging (dMRI). We examined diffusion tensor parameters in warfighters using dMRI within the hypothalamus of poor sleepers and compared them to good sleepers.

Methods

A retrospective review of 92 warfighters with blast TBI and loss of consciousness included demographics, structural MRI, dMRI, PSG and Pittsburgh Sleep Quality Index (PSQI) questionnaire. Acquisition of diffusion-weighted and structural data was performed with three Tesla MRI. Using the California Institute of Technology probabilistic high-resolution in vivo atlas as a prior, the hypothalamic nuclei were segmented by applying diffeomorphic registration of T1- and T2-weighted structural images and mapped to dMRI space.

Results

TBI patients within the lowest quartile of hypothalamic fractional anisotropy (FA) measures demonstrated decreased total sleep time (320 +/- 52 minutes vs. 382 +/- 19, p=0.006) on PSG and had more sleep complaints on PSQI (p=0.029) compared to those with the highest quartile of FA measures. There was no difference in BMI, age or AHI among the quartiles. Radial, mean and axial diffusivity quartiles did not carry significant differences in TST or PSQI. Linear models did not show significant correlation between any imaging parameter and sleep quality measures.

Conclusion

Our results reveal microstructural differences in the hypothalami of military TBI patients that may be related to clinical sleep dysfunction. Biomarkers of sleep circuitry damage may further our understanding of sleep dysfunction after TBI. Lack of correlations in linear models may be a reflection of the small sample size or a complex interaction, and removal of outliers did not change our results. Larger longitudinal studies may help clarify the association between hypothalamic and brainstem circuitry structure after TBI and sleep dysfunction.

Support

This work was supported by a grant 130132 from USAMRMC.

0416 Poor Sleep Quality Predicts Serum Markers of Neurodegeneration and Cognitive Deficits in Warriors with Mild Traumatic Brain Injury

Introduction

Increasing evidence links neurodegeneration to traumatic brain injury (TBI), and a separate body of literature links neurodegeneration to sleep dysfunction, implicating increased toxin production and decreased glymphatic clearance. Sleep disorders affect 50% of TBI patients, yet the sleep-neurodegeneration connection in these patients remains unexplored. We hypothesized that warfighters with TBI and sleep dysfunction would have increased neuronal injury, revealing potential mechanistic underpinnings for TBI outcomes. We measured plasma biomarkers, cognitive function and sleep surveys for correlation analysis.

Methods

In a retrospective cross-sectional study of warfighters (n=113 chronic mild TBI patients), the Pittsburgh sleep quality index (PSQI) was compared with amyloid β42 (Aβ42), neurofilament light (NFL), tau, and phospho-tau (threonine 181) isolated from plasma and exosomes. Executive function was tested with the categorical fluency test. Exosomes were precipitated from plasma. Proteins were measured with the Single Molecule Array (Quanterix). Linear models were adjusted for age, ApoE, and number of TBIs.

Results

Poor sleepers with TBI (PSQI>8) had elevated NFL compared to good sleepers in plasma (p=0.007) and exosomes (p=0.00017), and PSQI directly correlated with NFL (plasma: Beta=0.23, p=0.0079; exosomes: Beta=2.19, p=0.0013) stronger than any other marker of neurodegeneration. Poor sleepers also showed higher obstructive sleep apnea (OSA) risk compared to good sleepers by STOP-BANG scores (3.6, SD=1.6 vs 2.8, SD=1.74; p=0.0014) as well as decreased categorical fluency (20.7, SD=4.1) (18.3, SD=4.6, p=.0067). Plasma tau and Aβ42 also correlated with PSQI (Beta=0.64, p=0.028, and Beta=0.40, p=0.049 respectively).

Conclusion

This is the first reported data correlating markers of neuronal injury and cognitive deficits with sleep complaints and OSA risk in patients with TBI - possibly identifying treatable pathophysiological mediators of TBI neurodegeneration. Limitations include a small sample size, lack of objective sleep measures, and inability to establish directionality due to cross-sectional design. Prospective trials will be required to further explore our proposed hypothesis. If confirmed, these findings would call for targeting sleep disorders in the TBI population to mitigate risk of neurodegeneration.

Support

This work was supported by grant funding from: Department of Defense, Chronic Effects of Neurotrauma Consortium (CENC) Award W81XWH-13-2-0095 and Department of Veterans Affairs CENC Award I01 CX001135.

1155 The Association Between STOPBANG Risk and Sleep Quality in an mTBI Sample

Introduction

Although Obstructive Sleep Apnea (OSA) is prevalent in the military population, traditional scoring/clinical cut-offs of available screening tools may not be appropriate for this younger, slimmer population. We additionally have limited information regarding utility of OSA screening in those with history of mild traumatic brain injury (mTBI). The current study compared multiple STOPBANG scoring methods to determine how well they were associated with self-reported sleep measures in an mTBI sample.

Methods

Secondary analyses were conducted from a large database of evaluations from a multi-center, longitudinal study of mTBI. Participants were included if they had completed the STOPBANG and additional sleep measures. The subsequent sample (N=486) included participants with history of mTBI (n=408) and controls (n=78). The sample was predominantly male (n=421) with a mean age of 39 (IQR = 31/37/47).

Results

Sleep efficiency was not significantly associated with any STOPBANG scoring, in the total sample or when controlling for mTBI. In the total sample, sleep quality was most strongly associated with traditional STOPBANG scoring (STOPBANG ≥ 3, β=0.51). Sleep duration was most strongly associated with Snoring/Tired/Hypertension (STP = 3, β=0.79). When controlling for mTBI, duration was most strongly associated with traditional scoring (β=0.48), while sleep quality was most strongly associated with Snoring/Tired/Hypertension (β=0.78). Follow-up analyses demonstrate a significant difference in correlation between groups for STP/Sleep Quality, with a stronger correlation for those without mTBI.

Conclusion

The STOPBANG measure was significantly associated with self-reported sleep quality/duration measures, but not sleep efficiency. Although traditional clinical cut-offs for OSA predicted sleep measures in this sample, the relationship between risk scores and outcomes became more nuanced when history of mTBI was included. Future studies are needed to understand the relationship between OSA risk and subsequent diagnosis in the mTBI population.

Support

Defense and Veterans Brain Injury Center (GDHS,W91YTZ-13-C-0015), DOD(W81XWH-12-2-0095), VA(I01 CX001135)

Improving the improvisational pelvic circumferential compression technique for open-book pelvic fractures using a simulation model and a sphygmomanometer

BACKGROUND

Open-book pelvic fractures are associated with significant mortality. Emergency management may require a commercial pelvic circumferential compression device to reduce the fracture and compress haemorrhaging pelvic vasculature. Standard, commercial, twin-sized bedsheets are acceptable should commercial devices be unavailable. However, obese victims or personnel with insufficient body strength may impede successful reduction.

OBJECTIVE

To demonstrate the value of an improvisational windlass (intravenous pole) in improving the ability to reduce an open-book pelvic fracture.

METHODS

The Institutional Review Board-approved study involved 28 diverse healthcare students and emergency medicine residents. Each participant's demographic information and physical characteristics were recorded. A METIman was prepared with knee and ankle binding and a sphygmomanometer set at 40 mm Hg placed over the symphysis pubis. Two-person teams were randomly selected to place a bedsheet at greater trochanter level and atop the sphygmomanometer. The bedsheet was secured with maximum effort by the pairs and the pressure recorded. Following this, the pairs inserted an intravenous pole in the knot and torqued the pole to maximum effort and a repeat pressure recorded.

RESULTS

The mean increase in pressure using only the bedsheet was 106.43 mm Hg per team. With bedsheet and intravenous pole, the mean pressure increase was 351.79 mm Hg per team. The difference was statistically significant (independent samples t-test: t = 17.177, p < 0.001, 95% CI (216.65 to 274.07 mm Hg). There was no correlation between pressure increases and the individual physical characteristics of the subjects (r = - 0.183, p = 0.352).

CONCLUSIONS

Regardless of personnel's physical attributes, the addition of an improvisational windlass to a pelvic circumferential compression bedsheet can improve the ability to reduce an open-book fracture, especially in obese victims.

Breast cancer screening of underserved women in the USA: results from the National Breast and Cervical Cancer Early Detection Program, 1998-2012

OBJECTIVE

To describe the number and proportion of eligible women receiving mammograms funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

Low-income, uninsured, and underinsured women aged 40-64 are eligible for mammography screening through the NBCCEDP. We used data from the NBCCEDP, the Current Population Survey, and Medical Expenditure Panel Survey to describe the number and proportion of women screened by the NBCCEDP and overall.

RESULTS

In 2011 and 2012, the NBCCEDP screened 549,043 women aged 40-64, an estimated 10.6 % (90 % confidence interval [CI] 10.4-10.9 %) of the eligible population. We estimate that 30.6 % (90 % CI 26.4-34.8 %) of eligible women aged 40-64 were screened outside the NBCCEDP, and 58.8 % (90 % CI 54.6-63.0 %) were not screened. The proportion of eligible women screened by the NBCCEDP varied across states, with an estimated range of 3.2 % (90 % CI 2.9-3.5 %) to 52.8 % (90 % CI 36.1-69.6 %) and a median of 13.7 % (90 % CI 11.0-16.4 %). The estimated proportion of eligible women aged 40-64 who received mammograms through the NBCCEDP was relatively constant over time, 11.1 % (90 % CI 10.2-11.9 %) in 1998-1999 and 10.6 % (90 % CI 10.4-11.9 %) in 2011-2012 (p = 0.23), even as the number of women screened increased from 343,692 to 549,043.

CONCLUSIONS

Although the NBCCEDP provided screening services to over a half million low-income uninsured women for mammography, it served a small percentage of those eligible. The majority of low-income, uninsured women were not screened.

Cervical cancer screening of underserved women in the United States: results from the National Breast and Cervical Cancer Early Detection Program, 1997-2012

OBJECTIVE

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screens to low-income, uninsured, and underinsured women. We describe the number and proportion of women eligible for cervical cancer screening services and the proportion of eligible women screened over the period 1997-2012.

METHODS

Low-income, uninsured, and underinsured women aged 18-64 years who have not had a hysterectomy are eligible for cervical cancer screening through the NBCCEDP. We estimated the number of low-income, uninsured women using data from the US Census Bureau. We adjusted our estimates for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used data from the NBCCEDP to describe the number of women receiving NBCCEDP-funded screening and calculated the proportion of eligible women who received screening through the NBCCEDP at the national level (by age group, race/ethnicity) and at the state level by age group. We used the Medical Expenditure Panel Survey to estimate the proportion of NBCCEDP-eligible women who were screened outside the NBCCEDP and the proportion that are not screened.

RESULTS

We estimate that in 2010-2012, 705,970 women aged 18-64 years, 6.5 % (705,970 of 9.8 million) of the eligible population, received NBCCEDP-funded Pap tests. We estimate that 60.2 % of eligible women aged 18-64 years were screened outside the NBCCEDP and 33.3 % were not screened. The NBCCEDP provided 623,603 screens to women aged 40-64 years, an estimated 16.5 % of the eligible population, and 83,660 screens to women aged 18-39 years, representing an estimated 1.2 % of the eligible population. The estimated proportions of eligible women screened in each state ranged from 1.5 to 32.7 % and 5 % to 73.2 % among the 18-64 and 40-64 years age groups, respectively. Changes in the proportion of eligible women screened over the study period were nonsignificant.

CONCLUSIONS

Although the program provided cervical screening to over 700,000 women between 2010 and 2012, it served a small percent of those eligible. The proportion of women screened varied substantially across age groups, racial/ethnic groups, and states. Many low-income, uninsured women are not being screened.

Whole blood gene expression profiles distinguish clinical phenotypes of venous thromboembolism

INTRODUCTION

Recurrent venous thromboembolism (VTE) occurs infrequently following a provoked event but occurs in up to 30% of individuals following an initial unprovoked event. There is limited understanding of the biological mechanisms that predispose patients to recurrent VTE.

OBJECTIVES

To identify whole blood gene expression profiles that distinguished patients with clinically distinct patterns of VTE.

PATIENTS/METHODS

We studied 107 patients with VTE separated into 3 groups: (1) 'low-risk' patients had one or more provoked VTE; (2) 'moderate-risk' patients had a single unprovoked VTE; (3) 'high-risk' patients had ≥2 unprovoked VTE. Each patient group was also compared to twenty-five individuals with no personal history of VTE. Total RNA from whole blood was isolated and hybridized to Illumina HT-12V4 Beadchips to assay whole genome expression.

RESULTS

Using class prediction analysis, we distinguished high-risk patients from low-risk patients and healthy controls with good receiver operating curve characteristics (AUC=0.81 and 0.84, respectively). We also distinguished moderate-risk individuals and low-risk individuals from healthy controls with AUC's of 0.69 and 0.80, respectively. Using differential expression analysis, we identified several genes previously implicated in thrombotic disorders by genetic analyses, including SELP, KLKB1, ANXA5, and CD46. Protein levels for several of the identified genes were not significantly different between the different groups.

CONCLUSION

Gene expression profiles are capable of distinguishing patients with different clinical presentations of VTE, and genes relevant to VTE risk are frequently differentially expressed in these comparisons.

Transfusion complications in thalassemia patients: a report from the Centers for Disease Control and Prevention (CME)

BACKGROUND

Transfusions are the primary therapy for thalassemia but have significant cumulative risks. In 2004, the Centers for Disease Control and Prevention (CDC) established a national blood safety monitoring program for thalassemia. This report summarizes the population and their previous nonimmune and immune transfusion complications.

STUDY DESIGN AND METHODS

The CDC Thalassemia Blood Safety Network is a consortium of centers longitudinally following patients. Enrollment occurred from 2004 through 2012. Demographics, transfusion history, infectious exposures, and transfusion and nontransfusion complications were summarized. Logistic regression analyses of factors associated with allo- and autoimmunization were employed.

RESULTS

The race/ethnicity of these 407 thalassemia patients was predominantly Asian or Caucasian. The mean ± SD age was 22.3 ± 13.2 years and patients had received a mean ± SD total number of 149 ± 103.4 units of red blood cells (RBCs). Multiorgan dysfunction was common despite chelation. Twenty-four percent of transfused patients had previous exposure to possible transfusion-associated pathogens including one case of babesia. As 27% were immigrants, the infection source cannot be unequivocally linked to transfusion. Transfusion reactions occurred in 48%, including allergic, febrile, and hemolytic; 19% were alloimmunized. Common antigens were E, Kell, and C. Years of transfusion was the strongest predictor of alloimmunization. Autoantibodies occurred in 6.5% and were associated with alloimmunization (p < 0.0001). Local institutional policies, not patient characteristics, were major determinants of blood preparation and transfusion practices.

CONCLUSION

Hemosiderosis, transfusion reactions, and infections continue to be major problems in thalassemia. New pathogens were noted. National guidelines for RBC phenotyping and preparation are needed to decrease transfusion-related morbidity.

Abstract P4-12-04: Association of single-strand breaks (SSBs) in normal breast DNA with estimates of breast cancer risk

Background: Formation of single strand breaks in DNA is a constant process, estimated to occur 10,000 times per day in each cell, either from endogenous biosynthetic errors or from interference by endogenous or exogenous agents. Base excision repair in some cases may be impaired or may be exceeded by the rate of DNA damage, leading to cancer. Nick translation of with labeled nucleotides can be used as a quantitative indicator of SSBs.

Methods: Healthy women were recruited through the Love-Avon Army of Women and breast clinics of Northwestern and John Hopkins Universities. Digital or digitized mammograms were evaluated for percent density using Cumulus software. The medians (ranges) were age 51 (36 to 60); BMI 28.2 (18.7 to 51.3); life-time Gail estimate 12.5 (5.6 to 28.3); % breast density 16.5 (2.4 to 52.5); Masood score 13 (0 to 18). Breast tissue was obtained by random fine needle aspiration (rFNA). Specimens were rinsed into ice-cold phosphate buffered saline and were stored at −80°C. Thawed samples were centrifuged at 2200 g for 60 min. A kit from Norgen Inc., was used to separate DNA, RNA, and protein from the pellet. The lipids were extracted with ethyl acetate-hexane (3:2) from the supernatant fluid, and triglycerides were precipitated from cold 90% methanol, leaving a purified lipid fraction containing the steroids. Steroids were then fractionated by HPLC on a C18 column, and estradiol was analyzed by a radioimmunoassay. Blood was obtained at the same time as the rFNA samples and was frozen prior to analysis. An aliquot containing 200 ng of DNA (260/280 ratio 1.3 to 2.3) was taken for the nick translation assay. Incorporation of free nucleotides at SSBs with dCTP labeled with3H was catalyzed by Polymerase I from E. coli. A quality control preparation prepared from calf thymus DNA and a reagent blank without DNA was included with each set of 6 samples. Incorporation of3H-dCTP was linear with dose of DNA and reached a maximal at 30 min. Separation of free from incorporated3H-dCTP was accomplished by gel chromatography on an 80 × 15 mm column. The concordance of interassay values was 0.96.

Syphilis partner notification with men who have sex with men: a review and commentary

BACKGROUND

Eight US cities experienced large outbreaks of syphilis among men having sex with men (MSM), beginning during 2000-2001. Provider-assisted partner notification via disease intervention specialists has traditionally composed a large part of syphilis control efforts.

OBJECTIVES

Report current effectiveness of syphilis partner notification for MSM and identify related problems and solutions.

RESULTS

One thousand five hundred seventeen MSM diagnosed with syphilis claimed 10,254 sex partners. Many claimed anonymous partners (median = 65%), or provided insufficient locating information (median = 42%). Median cases found per index case were 0.09 (total = 116), although an additional 197 partners had been previously treated. Principal impediments to partner notification fell into 3 areas: (1) diagnosis outside health department settings delayed interviews, (2) partners were often anonymous, and (3) mistrust among MSM, public health professionals, and health care providers in private settings.

CONCLUSIONS

Characteristics of the current outbreaks among MSM make traditional partner notification more difficult than in the past. Some modifications, complements, and even alternatives to partner notification are either planned or in operation.

An enzyme-linked immunosorbent assay to quantify 14-3-3 proteins in the cerebrospinal fluid of suspected Creutzfeldt-Jakob disease patients

The detection of 14-3-3 protein by Western immunoblot is a sensitive and specific cerebrospinal fluid marker of Creutzfeldt-Jakob disease (CJD). We developed a quantitative enzyme-linked immunosorbent assay (ELISA) that reliably detects 14-3-3 in cerebrospinal fluid. In a prospective study of 147 cerebrospinal fluid samples, the mean 14-3-3 concentration among pathologically confirmed CJD patients (28.0+/-20.6 ng/ml, n = 41) is significantly higher than the mean in the cerebrospinal fluid of those with other neurological disorders (3.1+/-2.9 ng/ ml, n = 84). At a cutoff value of 8.3 ng/ml, the ELISA has a sensitivity of 92.7% and a specificity of 97.6%. The 14-3-3 ELISA supports a diagnosis of CJD in patients who fulfill clinical criteria for possible CJD.

Increased levels of epsilon and gamma isoforms of 14-3-3 proteins in cerebrospinal fluid in patients with Creutzfeldt-Jakob disease

We established four hybridoma cell lines producing monoclonal antibodies (MAbs) against 14-3-3 proteins. Immunoblot analysis revealed that epsilon and gamma isoforms were specifically increased in premortem cerebrospinal fluid samples from patients with sporadic Creutzfeldt-Jakob disease. Furthermore, dot immunoblot analysis showed that MAbs were more specific for native antigen than polyclonal antibodies were.

The 14-3-3 brain protein in cerebrospinal fluid as a marker for transmissible spongiform encephalopathies

BACKGROUND

There is no practical and reliable premortem test for Creutzfeldt-Jakob disease and the related transmissible spongiform encephalopathies. Two proteins, designated 130 and 131, which have been detected in low concentrations in cerebrospinal fluid from patients with Creutzfeldt-Jakob disease, appear to be sensitive and specific markers for the disease. Attempts to identify these proteins, however, have been unsuccessful. We hypothesized that they may be present in the normal brain.

METHODS

We detected proteins 130 and 131 in normal human brain, partially sequenced their amino acids, and found that they matched the brain protein known as 14-3-3. We then developed a simple, rapid immunoassay for this protein and tested it in cerebrospinal fluid samples from 71 humans and 30 animals with spongiform encephalopathies and in control samples from 186 humans and 94 animals.

RESULTS

The immunoassay detected the 14-3-3 protein in cerebrospinal fluid from 68 of the 71 patients with Creutzfeldt-Jakob disease (96 percent, 95 percent confidence interval, 92 to 99 percent). Among 94 patients with other dementias, the specificity was 96 percent. If one excludes the three patients with dementia who had strokes within one month before testing, the specificity was 99 percent. The test was positive in 12 of 24 patients with viral encephalitis. In animals the sensitivity of the assay was 87 percent and the specificity was 99 percent.

CONCLUSION

In patients with dementia, a positive immunoassay for the 14-3-3 brain protein in cerebrospinal fluid strongly supports a diagnosis of Creutzfeldt-Jakob disease. This finding, however, does not support the use of the test in patients without clinically evident dementia.

Familial Creutzfeldt-Jakob disease with a five-repeat octapeptide insert mutation

We report a familial form of Creutzfeldt-Jakob disease, associated with a unique insert mutation of the PRNP gene in an American family of Ukrainian origin. Ten family members exhibited early age at onset and long-duration illnesses characterized primarily by personality changes, cognitive impairment, and spasticity. The proband, presenting at age 42 years, exhibited a fairly stable, nonprogressive course over 7 years, followed by precipitous decline and death in the eighth year. Other affected family members exhibited marked clinical heterogeneity. Each tested affected member had an insert mutation consisting of five extra octapeptide repeats between codons 51 and 91 of the PRNP gene on chromosome 20. Examination of two autopsy cases showed classic spongiform change, neuronal loss and astrocytosis in one case, and minimal pathologic abnormality in the other case. This report documents a new insert mutation of the PRNP gene, and confirms the early age of onset, characteristically prolonged clinical course, and clinical and pathologic heterogeneity seen in such mutations.

Relationship of lumbar strength in shipyard workers to workplace injury claims

STUDY DESIGN

Strength testing of lumbar extensors of shipyard workers without back injury claims was accomplished to compare isolated lumbar strength with the severity of their workplace physical demands and the incidence of workplace back injury during a 2-year period.

OBJECTIVES

To determine if strength is a predictor of workplace injury and if there is a relationship between the physical demands of the job and strength.

SUMMARY OF BACKGROUND DATA

The role of preplacement strength testing has not been clarified as a potential means for predicting workplace injury. It has not been clarified whether work activity affects the strength of the worker.

METHODS

One hundred fifty-two shipyard workers were strength tested for isometric lumbar extensor strength. They had been classified as to the severity of their job demands according to the Physical Demand Characteristics. All workers at this industry were likewise classified. Those workers who were tested were followed for 2 years to evaluate for claims of back injury.

RESULTS

There was a higher incidence of low back injuries in the heavy and very heavy classification. There was, however, no difference in strength among those workers classified in medium, heavy, and very heavy work. Nine percent of those workers tested had back pains during the following 2 years. All but two had higher-than-average strength.

CONCLUSIONS

There is no evidence that preplacement back strength testing would predict workplace claims of injury.

Applied physiology of water-skiing

Water-skiing is a physically demanding sport involving highly coordinated movements, extreme upper body torques, sustained isometric contractions and near maximal stresses on the anaerobic system. Due to the physical demands of the sport, elite skiers have developed physiological characteristics similar to other elite athletes. However, until recently little research has focused on the kinesiology, physiology and physical conditioning of water-skiing.

Intracerebral distribution of infectious amyloid protein in spongiform encephalopathy

We studied the regional distribution of infectious amyloid protein by western immunoblots of brain tissue extracts from 37 patients with different forms of spongiform encephalopathy, i.e., 16 sporadic cases, 18 familial cases with a variety of mutations, and 3 iatrogenic cases. In sporadic and familial Creutzfeldt-Jakob disease, amyloid protein concentrations were usually highest in the frontotemporal regions of the cerebral cortex, whereas iatrogenic Creutzfeldt-Jakob disease and Gerstmann-Sträussler-Scheinker syndrome had as high or higher concentrations in the deep cerebral nuclei and cerebellum. As a group, familial cases had lower amyloid protein concentrations than either sporadic or iatrogenic cases, and fatal familial insomnia patients had the lowest concentrations found in any form of disease. This hierarchy of amyloid protein concentrations corresponds to the experimental transmission rates observed for each form of disease and is consistent with the concept that the protein molecule is an integral component of the infectious agent. Regional amyloid protein pattern analysis of brain and spinal cord may help to distinguish sporadic from environmentally acquired infections, as for example, cases of human disease suspected to have arisen from exposure to sheep or cows infected with scrapie or bovine spongiform encephalopathy.

The effect of lumbar belts on isolated lumbar muscle. Strength and dynamic capacity

STUDY DESIGN

This study analyzed the effect of lumbar support belts on functional performance.

OBJECTIVE

To compare lumbar muscle strength and lifting capacity with and without a lumbar belt.

SUMMARY OF BACKGROUND DATA

Industrialized settings have begun to encourage the use of lumbar support belts for their employees. It is believed that the belts may decrease the risk of injury and enhance the functional performance of the individual.

METHODS

Twenty-two subjects (average age, 27.5 years) were tested on four separate days to evaluate the effect of a commercially available belt on isolated lumbar isometric strength and functional dynamic lifting capacity. All subjects had no history of low back problems. The order of testing with and without a belt was randomized for both conditions. On the first 2 days, subjects performed a seven-angle isometric lumbar extension strength test, 1 day with and 1 day without a lumbar belt. On the following 2 days, subjects were tested to evaluate functional capacity with and without a lumbar belt. The functional capacity evaluation was performed by progressively lifting weighted canisters from various levels. Heart rates were monitored to ensure that a maximum effort was achieved over the different days.

RESULTS

T tests revealed that isometric lumbar strength and functional lifting capacity was not significantly affected by the belt.

CONCLUSION

The use of a lumbar belt does not enhance isometric lumbar muscle strength or dynamic lifting capacity.

A new (two-repeat) octapeptide coding insert mutation in Creutzfeldt-Jakob disease

We report a family in which the proband died of clinically typical, neuropathologically verified Creutzfeldt-Jakob disease; her still-living mother suffers from a progressive dementia of many years' duration, and her maternal grandfather died after a similar illness. The proband, her mother, and two of three young first-degree relatives all have an identical insert mutation in the PRNP gene consisting of a twice-repeated 24-nucleotide sequence in the region between codons 51 and 91.