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O'Sullivan MJ, Jang JH, Panariti A, Bedrat A, Ijpma G, Lemos B, Park JA, Lauzon AM, Martin JG. Airway Epithelial Cells Drive Airway Smooth Muscle Cell Phenotype Switching to the Proliferative and Pro-inflammatory Phenotype. Front Physiol 2021; 12:687654. [PMID: 34295265 PMCID: PMC8290262 DOI: 10.3389/fphys.2021.687654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022] Open
Abstract
The increased mass of airway smooth muscle (ASM) in the airways of asthmatic patients may contribute to the pathology of this disease by increasing the capacity for airway narrowing. Evidence for the airway epithelium as a participant in ASM remodeling is accruing. To investigate mechanisms by which airway epithelial cells induce ASM cell (ASMC) proliferation, we have employed a co-culture model to explore markers of ASMC proliferative phenotype. Co-culture with epithelial cells led to incorporation of bromodeoxyuridine into ASMCs, indicating augmented proliferation and an associated increase in mRNA of the pro-proliferative co-transcription factor Elk1. Although the mitogen heparin-binding epidermal growth factor (HB-EGF) was augmented in the co-culture supernatant, the ASMC epidermal growth factor receptor (EGFR), an effector of HB-EGF induced proliferation, did not mediate epithelial-induced proliferation. The co-culture increased the expression of ASMC mRNA for the pro-inflammatory cytokines IL-6 and IL-8 as well as the pro-proliferative microRNA miR-210. The transcriptional repressor Max-binding protein (Mnt), a putative target of miR-210, was transcriptionally repressed in co-cultured ASMCs. Together, these data indicate that the airway epithelium-induced proliferative phenotype of ASMCs is not driven by EGFR signaling, but rather may be dependent on miR210 targeting of tumor suppressor Mnt.
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Affiliation(s)
- M J O'Sullivan
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada.,T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - J H Jang
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
| | - A Panariti
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
| | - A Bedrat
- T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - G Ijpma
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
| | - B Lemos
- T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - J A Park
- T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - A M Lauzon
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
| | - J G Martin
- Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
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Cullinane CM, Creavin B, O'Connell EP, Kelly L, O'Sullivan MJ, Corrigan MA, Redmond HP. Risk of colorectal cancer associated with BRCA1 and/or BRCA2 mutation carriers: systematic review and meta-analysis. Br J Surg 2020; 107:951-959. [PMID: 32297664 DOI: 10.1002/bjs.11603] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Carriers of the BRCA1 and/or BRCA2 mutation incur a lifetime risk of up to 85 per cent for breast cancer, and between 20 and 40 per cent for ovarian cancer. Efforts to estimate the lifetime risk of developing colorectal cancer for BRCA mutation carriers have produced conflicting results. Consequently, there are no formal guidelines regarding the need for bowel screening for individuals with BRCA1 and/or BRCA2 mutations. This systematic review and meta-analysis determined the risk of colorectal cancer associated with BRCA carrier mutations. METHODS The primary outcome was incidence of colorectal cancer in BRCA mutation carriers. Secondary outcomes were the incidence in BRCA1 and BRCA2 carriers, Ashkenazi Jews, and age- and sex-matched cohorts. RESULTS Eleven studies were included in the review, with an overall population of 14 252 and 4831 colorectal cancers identified. Nine studies were included in the meta-analysis. There was no increase in colorectal cancer among patients carrying a BRCA mutation (odds ratio 1·03, 95 per cent c.i. 0·80 to 1·32; P = 0·82). After adjustment for Ashkenazi heritage, and age and sex estimates, there was no increased odds of developing colorectal cancer (with no heterogeneity, I2 = 0 per cent). CONCLUSION BRCA1 and/or BRCA2 mutation carriers are not at a higher risk of colorectal cancer.
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Affiliation(s)
- C M Cullinane
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - B Creavin
- Department of General Surgery, University Hospital Kerry, Tralee, Ireland
| | - E P O'Connell
- Department of General Surgery, University Hospital Kerry, Tralee, Ireland
| | - L Kelly
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - M J O'Sullivan
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - M A Corrigan
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - H P Redmond
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
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Buhimschi CS, Jablonski KA, Rouse DJ, Varner MW, Reddy UM, Mercer BM, Leveno KJ, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter MW, O'Sullivan MJ, Peaceman AM, Saade GR, Dudley D, Caritis SN, Buhimschi IA. Cord Blood Haptoglobin, Cerebral Palsy and Death in Infants of Women at Risk for Preterm Birth: A Secondary Analysis of a Randomised Controlled Trial. EClinicalMedicine 2019; 9:11-18. [PMID: 31143877 PMCID: PMC6510719 DOI: 10.1016/j.eclinm.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antenatal exposure to intra-uterine inflammation results in precocious Haptoglobin (Hp) expression (switch-on status). We investigated the relationships between foetal Hp expression at birth with newborn and childhood outcomes. METHODS We evaluated cord blood samples from 921 newborns of women at imminent risk for preterm delivery randomised to either placebo (n = 471, birth gestational age (GA) median [min-max]: 31 [24-41] weeks) or magnesium sulphate (n = 450, GA 31 [24-42] weeks]). Primary outcome was infant death by 1 year and/or cerebral palsy (CP) ≥ 2 years of corrected age. Adjusted odd ratios (aOR) for neonatal and childhood outcomes were calculated controlling for GA, birth weight, sex, and magnesium exposure. FINDINGS Primary outcome occurred in 2.8% of offspring. Newborns were classified in three pre-defined categorisation groups by cord blood Hp switch status and IL-6 levels: inflammation-nonexposed (Category 1, n = 432, 47%), inflammation-exposed haptoglobinemic (Category 2, n = 449, 49%), and inflammation-exposed anhaptoglobinemic or hypohaptoglobinemic (Category 3, n = 40, 4%). Newborns, found anhaptoglobinemic or hypohaptoglobinemic (Category 3) had increased OR for intraventricular haemorrhage (IVH) and/or death (aOR: 7.0; 95% CI: 1.4-34.6, p = 0.02) and for CP and/or death (aOR: 6.27; 95% CI: 1.7-23.5, p = 0.006) compared with Category 2. Foetal ability to respond to inflammation by haptoglobinemia resulted in aOR similar to inflammation-nonexposed newborns. Hp1-2 or Hp2-2 phenotypes protected against retinopathy of prematurity (aOR = 0.66; 95% CI 0.48-0.91, p = 0.01). INTERPRETATION Foetal ability to switch-on Hp expression in response to inflammation was associated with reduction of IVH and/or death, and CP and/or death. Foetuses unable to mount such a response had an increased risk of adverse outcomes.Trial Registration: clinicaltrials.gov Identifier: NCT00014989.
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Affiliation(s)
- Catalin S. Buhimschi
- Department of Obstetrics and Gynaecology, The Ohio State University, Columbus, OH, United States of America
- Corresponding author at: Department of Obstetrics & Gynecology, University of Illinois at Chicago, Chicago, IL 60612, United States of America.
| | - Kathleen A. Jablonski
- The George Washington University Biostatistics Center, Washington, DC, United States of America
| | - Dwight J. Rouse
- University of Alabama at Birmingham, Birmingham, AL, United States of America
| | | | - Uma M. Reddy
- the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States of America
| | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, United States of America
- University of Tennessee, Memphis, TN, United States of America
| | | | - Ronald J. Wapner
- Thomas Jefferson University, Philadelphia, PA, United States of America
- Drexel University, Philadelphia, PA, United States of America
| | - Yoram Sorokin
- Wayne State University, Detroit, MI, United States of America
| | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | | | | | | | | | - George R. Saade
- University of Texas Medical Branch, Galveston, TX, United States of America
| | - Donald Dudley
- University of Texas at San Antonio, San Antonio, TX, United States of America
| | - Steve N. Caritis
- University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Irina A. Buhimschi
- Centre for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States of America
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Gan CL, O'Sullivan MJ, Metzler-Baddeley C, Halpin S. Association of imaging abnormalities of the subcallosal septal area with Alzheimer's disease and mild cognitive impairment. Clin Radiol 2017; 72:915-922. [PMID: 28859851 PMCID: PMC5633012 DOI: 10.1016/j.crad.2017.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 12/30/2016] [Accepted: 04/12/2017] [Indexed: 11/16/2022]
Abstract
AIM To evaluate the use the distance between the adjacent septal nuclei as a surrogate marker of septal area atrophy seen in Alzheimer's disease (AD). MATERIALS & METHODS Interseptal distance (ISD) was measured, blind to clinical details, in 250 patients who underwent computed tomography (CT) of the brain at University Hospital of Wales. Clinical details including memory problem history were retrieved. An ISD cut-off value that discriminated those with and without memory symptoms was sought. ISD measurements were also made in 20 AD patients. To test both the method and the defined cut-off, measurements were then made in an independent cohort of 21 mild cognitive impairment (MCI) patients and 45 age-matched healthy controls, in a randomised and blinded fashion. RESULTS ISD measurement was achieved in all patients. In 28 patients with memory symptoms, the mean ISD was 5.9 mm compared with 2.3 mm in those without overt symptoms (p=0.001). The optimum ISD cut-off value was 4 mm (sensitivity 85.7% and specificity 85.8%). All AD patients had an ISD of >4 mm (mean ISD= 6.1 mm). The mean ISD for MCI patients was 3.84 mm compared with 2.18 mm in age-matched healthy controls (p=0.001). Using a 4 mm cut-off correctly categorised 10 mild cognitive impairment patients (47.6%) and 38 healthy controls (84.4%). CONCLUSION ISD is a simple and reliable surrogate measurement for septal area atrophy, applicable to CT and magnetic resonance imaging (MRI). It can be used to help select patients for further investigation.
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Affiliation(s)
- C L Gan
- Department of Neuroradiology, University Hospital of Wales, Cardiff, UK.
| | - M J O'Sullivan
- Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff, UK; Department of Clinical Neuroscience, Institute of Psychiatry, King's College London, London, UK
| | - C Metzler-Baddeley
- Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff, UK
| | - S Halpin
- Department of Neuroradiology, University Hospital of Wales, Cardiff, UK
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Giri A, Hartmann KE, Aldrich MC, Ward RM, Wu JM, Park AJ, Graff M, Qi L, Nassir R, Wallace RB, O'Sullivan MJ, North KE, Velez Edwards DR, Edwards TL. Admixture mapping of pelvic organ prolapse in African Americans from the Women's Health Initiative Hormone Therapy trial. PLoS One 2017; 12:e0178839. [PMID: 28582460 PMCID: PMC5459562 DOI: 10.1371/journal.pone.0178839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 05/19/2017] [Indexed: 12/27/2022] Open
Abstract
Evidence suggests European American (EA) women have two- to five-fold increased odds of having pelvic organ prolapse (POP) when compared with African American (AA) women. However, the role of genetic ancestry in relation to POP risk is not clear. Here we evaluate the association between genetic ancestry and POP in AA women from the Women’s Health Initiative Hormone Therapy trial. Women with grade 1 or higher classification, and grade 2 or higher classification for uterine prolapse, cystocele or rectocele at baseline or during follow-up were considered to have any POP (N = 805) and moderate/severe POP (N = 156), respectively. Women with at least two pelvic exams with no indication for POP served as controls (N = 344). We performed case-only, and case-control admixture-mapping analyses using multiple logistic regression while adjusting for age, BMI, parity and global ancestry. We evaluated the association between global ancestry and POP using multiple logistic regression. European ancestry at the individual level was not associated with POP risk. Case-only and case-control local ancestry analyses identified two ancestry-specific loci that may be associated with POP. One locus (Chromosome 15q26.2) achieved empirically-estimated statistical significance and was associated with decreased POP odds (considering grade ≥2 POP) with each unit increase in European ancestry (OR: 0.35; 95% CI: 0.30, 0.57; p-value = 1.48x10-5). This region includes RGMA, a potent regulator of the BMP family of genes. The second locus (Chromosome 1q42.1-q42.3) was associated with increased POP odds with each unit increase in European ancestry (Odds ratio [OR]: 1.69; 95% confidence interval [CI]: 1.28, 2.22; p-value = 1.93x10-4). Although this region did not reach statistical significance after considering multiple comparisons, it includes potentially relevant genes including TBCE, and ACTA1. Unique non-overlapping European and African ancestry-specific susceptibility loci may be associated with increased POP risk.
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Affiliation(s)
- Ayush Giri
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Katherine E. Hartmann
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melinda C. Aldrich
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Renee M. Ward
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jennifer M. Wu
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Amy J. Park
- Department of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, District of Columbia, United States of America
| | - Mariaelisa Graff
- Department of Epidemiology, Gillings School of Global Public health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Lihong Qi
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of California, Davis, Davis, California, United States of America
| | - Rami Nassir
- Department of Biochemistry and Molecular Medicine, University of California, Davis, Davis, California, United States of America
- Department of Internal Medicine, University of California, Davis, Davis, California, United States of America
| | - Robert B. Wallace
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, United States of America
| | - Mary J. O'Sullivan
- Department of Obstetrics and Gynecology, Miller School of Medicine, Miami, Florida, United States of America
| | - Kari E. North
- Department of Epidemiology, Gillings School of Global Public health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Digna R. Velez Edwards
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Todd L. Edwards
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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Rutherford EJ, Kelly J, Lehane EA, Livingstone V, Cotter B, Butt A, O'Sullivan MJ, O Connell F, Redmond HP, Corrigan MA. Health literacy and the perception of risk in a breast cancer family history clinic. Surgeon 2016; 16:82-88. [PMID: 27908542 DOI: 10.1016/j.surge.2016.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/23/2016] [Accepted: 06/02/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Informed consent is an essential component of medical practice, and especially so in procedural based specialties which entail varying degrees of risk. Breast cancer is one of the most common cancers in women, and as such is the focus of extensive research and significant media attention. Despite this, considerable misperception exists regarding the risk of developing breast cancer. AIMS This study aims to examine the accuracy of risk perception of women attending a breast cancer family history clinic, and to explore the relationship between risk perception accuracy and health literacy. METHODS A cross-sectional study of women attending a breast cancer family history clinic (n = 86) was carried out, consisting of a patient survey and a validated health literacy assessment. Patients' perception of personal and population breast cancer risk was compared to actual risk as calculated by a validated risk assessment tool. RESULTS Significant discordance between real and perceived risks was observed. The majority (83.7%) of women overestimated their personal lifetime risk of developing breast cancer, as well as that of other women of the same age (89.5%). Health literacy was considered potentially inadequate in 37.2% of patients; there was a correlation between low health literacy and increased risk perception inaccuracy across both personal ten-year (rs = 0.224, p = 0.039) and general ten-year population estimations. (rs = 0.267, p = 0.013). CONCLUSION Inaccuracy in risk perception is highly prevalent in women attending a breast cancer family history clinic. Health literacy inadequacy is significantly associated with this inaccuracy.
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Affiliation(s)
- E J Rutherford
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland; School of Medicine, University College Cork, Cork, Ireland
| | - J Kelly
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - E A Lehane
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - V Livingstone
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - B Cotter
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - A Butt
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - M J O'Sullivan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - F O Connell
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - H P Redmond
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland; School of Medicine, University College Cork, Cork, Ireland
| | - M A Corrigan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland.
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Fives C, O'Neill CJ, Murphy R, Corrigan MA, O'Sullivan MJ, Feeley L, Bennett MW, O'Connell F, Browne TJ. When pathological and radiological correlation is achieved, excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted. Breast 2016; 30:125-129. [PMID: 27718416 DOI: 10.1016/j.breast.2016.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/31/2016] [Accepted: 09/11/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up. METHODS A retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded. RESULTS 2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41-70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.
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Affiliation(s)
- C Fives
- Cork University Hospital, Wilton, Cork, Ireland
| | - C J O'Neill
- Cork University Hospital, Wilton, Cork, Ireland.
| | - R Murphy
- Cork University Hospital, Wilton, Cork, Ireland
| | | | | | - L Feeley
- Cork University Hospital, Wilton, Cork, Ireland
| | - M W Bennett
- Cork University Hospital, Wilton, Cork, Ireland
| | - F O'Connell
- Cork University Hospital, Wilton, Cork, Ireland
| | - T J Browne
- Cork University Hospital, Wilton, Cork, Ireland
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Dodds S, Nuehring EM, Blaney NT, Blakley T, Lizzotte JM, Lopez M, Potter JE, O'Sullivan MJ. Integrating Mental Health Services into Primary HIV Care for Women: The Whole Life Project. Public Health Rep 2016; 119:48-59. [PMID: 15147649 PMCID: PMC1502259 DOI: 10.1177/003335490411900111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The high rate of mental health problems in HIV-infected women jeopardizes the health of this vulnerable population, and constitutes a mandate for integrating mental health services into HIV primary care. The Whole Life project—a collaboration of the departments of Psychiatry and Obstetrics/Gynecology at the University of Miami School of Medicine—successfully integrated mental health services into primary HIV care for women. This article describes the conceptual framework of the integration, implementation strategies, effects of the service integration, and lessons learned. Funded by the Health Resources and Services Administration (HRSA) as a Special Program of National Significance (SPNS), Whole Life efforts have been sustained beyond the demonstration funding period as a result of the changes brought about in organizational structures, service delivery, and the providers' conceptualization of health for HIV-infected women.
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Affiliation(s)
- Sally Dodds
- Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, Miami, FL 33101, USA.
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9
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Zaslavsky O, Zelber-Sagi S, Gray SL, LaCroix AZ, Brunner RL, Wallace RB, O'Sullivan MJ, Cochrane B, Woods NF. Comparison of Frailty Phenotypes for Prediction of Mortality, Incident Falls, and Hip Fracture in Older Women. J Am Geriatr Soc 2016; 64:1858-62. [PMID: 27310179 DOI: 10.1111/jgs.14233] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the ability of the commonly used Women's Health Initiative (WHI) and Cardiovascular Health Study (CHS) frailty phenotypes to predict falls, hip fracture, and death in WHI Clinical Trial participants aged 65 and older. DESIGN Longitudinal cohort study. SETTING WHI Clinical Trial. PARTICIPANTS Participants with data for WHI and CHS frailty phenotypes (N = 3,558). MEASUREMENTS Frailty was operationally defined in the CHS as the presence of three or more of weight loss, poor energy, weakness, slowness, and low physical activity. WHI operationalized frailty similarly but with the RAND-36 physical function scale substituted for slowness and weakness (RAND-36 physical function scale score <13 = 2 points, 13-78 = 1 point, >78 = 0 points). Frailty was defined as a summary score of 3 or greater, prefrailty as a score of 2 or 1, and nonfrailty as a score of 0. Outcomes were modeled using Cox regression. Harrell C-statistics were compared for models containing alternative instruments. RESULTS Approximately 5% of participants were frail based on the CHS or WHI phenotype. The WHI frailty phenotype was associated with higher rates of falls (hazard ratio (HR) = 1.48, P = .003), hip fracture (HR = 1.87, P = .04), and death (HR = 2.32, P < .001). Comparable HRs in CHS-phenotype frail women were 1.32 (P = .04), 1.08 (P = .83), and 1.91 (P < .001), respectively. Harrell C-statistics revealed marked but insignificant differences in predicting abilities between CHS and WHI phenotype models (P > .50 for all). CONCLUSION The WHI phenotype, which does not require direct measurements of physical performance, might offer a practical advantage for epidemiological and clinical needs.
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Affiliation(s)
- Oleg Zaslavsky
- School of Nursing, University of Washington, Seattle, Washington.
| | - Shira Zelber-Sagi
- Faculty of Health Sciences and Social Welfare, University of Haifa, Haifa, Israel
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Andrea Z LaCroix
- Division of Epidemiology, School of Medicine, University of California at San Diego, San Diego, California
| | | | | | | | - Barbara Cochrane
- School of Nursing, University of Washington, Seattle, Washington
| | - Nancy F Woods
- School of Nursing, University of Washington, Seattle, Washington
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Walker CG, O'Sullivan MJ, Ziedins I, Furian N. Faster Cancer Treatment: Using timestamp data to improve patient journeys. Healthc (Amst) 2016; 4:252-258. [PMID: 28007222 DOI: 10.1016/j.hjdsi.2016.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/16/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
This paper presents a case study of research conducted to improve the delivery of treatment to high priority cancer patients. The authors present a modelling framework that uses time-stamp data collected by the North Shore Hospital IT systems as "business as usual", to describe the patient journey through the cancer-care process. A simulation process is developed that uses this data to estimate the service's performance under current operating practices, and enables "what-if" analysis to identify where changes to current practice can most effectively be applied, ensuring the investment of additional resource can be targeted at the steps of the patient pathway where it can result in the greatest improvement. The process is illustrated using the Breast Cancer stream as a case-study, for the initial study period (July 2013 to June 2014), with a follow-up analysis presented briefly for the 3 months from July to the end of September 2014.
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Affiliation(s)
- C G Walker
- University of Auckland, Engineering Science, 70 Symonds st, 3rd floor Uniservices House, New Zealand.
| | - M J O'Sullivan
- University of Auckland, Engineering Science, 70 Symonds st, 3rd floor Uniservices House, New Zealand
| | - I Ziedins
- University of Auckland, Engineering Science, 70 Symonds st, 3rd floor Uniservices House, New Zealand
| | - N Furian
- University of Auckland, Engineering Science, 70 Symonds st, 3rd floor Uniservices House, New Zealand
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11
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Chlebowski RT, Rohan TE, Manson JE, Aragaki AK, Kaunitz A, Stefanick ML, Simon MS, Johnson KC, Wactawski-Wende J, O'Sullivan MJ, Adams-Campbell LL, Nassir R, Lessin LS, Prentice RL. Breast Cancer After Use of Estrogen Plus Progestin and Estrogen Alone: Analyses of Data From 2 Women's Health Initiative Randomized Clinical Trials. JAMA Oncol 2016; 1:296-305. [PMID: 26181174 DOI: 10.1001/jamaoncol.2015.0494] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE The use of menopausal hormone therapy (HT) continues in clinical practice, but reports are conflicting concerning the longer-term breast cancer effects of relatively short-term use. OBJECTIVE To report the longer-term influence of menopausal HT on breast cancer incidence in the 2 Women's Health Initiative (WHI) randomized clinical trials. DESIGN, SETTING, AND PARTICIPANTS A total of 27,347 postmenopausal women aged 50 to 79 years were enrolled at 40 US centers from 1993 to 1998 and followed up for a median of 13 years through September 2010. INTERVENTIONS A total of 16,608 women with a uterus were randomized to conjugated equine estrogens (0.625 mg/d [estrogen]) plus medroxyprogesterone acetate (2.5 mg/d [progestin]) (E + P) or placebo with a median intervention duration of 5.6 years, and 10,739 women with prior hysterectomy were randomized to conjugated equine estrogens alone (0.625 mg/d) or placebo with a median intervention duration of 7.2 years. MAIN OUTCOMES AND MEASURES Time-specific invasive breast cancer incidence rates and exploratory analyses of breast cancer characteristics by intervention and postintervention phases in the 2 HT trials. RESULTS In the E + P trial, hazard ratios (HRs) for the influence of combined HT on breast cancer were lower than 1 for 2 years (HR, 0.71; 95% CI, 0.47-1.08) and steadily increased throughout intervention, becoming significantly increased for the entire intervention phase (HR, 1.24; 95% CI, 1.01-1.53). In the early postintervention phase (within 2.75 years from intervention), there was a sharp decrease in breast cancer incidence in the combined HT group, though the HR remained higher than 1 (HR, 1.23; 95% CI, 0.90-1.70). During the late postintervention phase (requiring patient re-consent), the HR for breast cancer risk remained higher than 1 through 5.5 years (median) of additional follow-up (HR, 1.37; 95% CI, 1.06-1.77). In the estrogen alone trial, the HR for invasive breast cancer risk was lower than 1 throughout the intervention phase (HR, 0.79; 95% CI, 0.61-1.02) and remained lower than 1 in the early postintervention phase (HR, 0.55; 95% CI, 0.34-0.89), but risk reduction was not observed during the late postintervention follow-up (HR, 1.17; 95% CI, 0.73-1.87). Characteristics of breast cancers diagnosed during early and late postintervention phases differed in both trials. CONCLUSIONS AND RELEVANCE In the E + P trial, the higher breast cancer risk seen during intervention was followed by a substantial drop in risk in the early postintervention phase, but a higher breast cancer risk remained during the late postintervention follow-up. In the estrogen alone trial, the lower breast cancer risk seen during intervention was sustained in the early postintervention phase but was not evident during the late postintervention follow-up.
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Affiliation(s)
- Rowan T Chlebowski
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Thomas E Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron K Aragaki
- Fred Hutchinson Cancer Research Center, Public Health Sciences, Seattle, Washington
| | - Andrew Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville
| | - Marcia L Stefanick
- Stanford Prevention Research Center, School of Medicine, Stanford University, Palo Alto, California
| | - Michael S Simon
- Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, Michigan
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Jean Wactawski-Wende
- Department of Social and Preventive Medicine, State University of New York at Buffalo
| | - Mary J O'Sullivan
- Obstetrics/Gynecology, University of Miami Health System Miami, Florida
| | | | - Rami Nassir
- Department of Biochemistry and Molecular Medicine, University of California, Davis
| | - Lawrence S Lessin
- Hematology and Medical Oncology, MedStar Washington Hospital Center, Washington, DC
| | - Ross L Prentice
- Fred Hutchinson Cancer Research Center, Public Health Sciences, Seattle, Washington
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12
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Giri A, Wu JM, Ward RM, Hartmann KE, Park AJ, North KE, Graff M, Wallace RB, Bareh G, Qi L, O'Sullivan MJ, Reiner AP, Edwards TL, Velez Edwards DR. Genetic Determinants of Pelvic Organ Prolapse among African American and Hispanic Women in the Women's Health Initiative. PLoS One 2015; 10:e0141647. [PMID: 26545240 PMCID: PMC4636147 DOI: 10.1371/journal.pone.0141647] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022] Open
Abstract
Current evidence suggests a multifactorial etiology to pelvic organ prolapse (POP), including genetic predisposition. We conducted a genome-wide association study of POP in African American (AA) and Hispanic (HP) women from the Women's Health Initiative Hormone Therapy study. Cases were defined as any POP (grades 1-3) or moderate/severe POP (grades 2-3), while controls had grade 0 POP. We performed race-specific multiple logistic regression analyses between SNPs imputed to 1000 genomes in relation to POP (grade 0 vs 1-3; grade 0 vs 2-3) adjusting for age at diagnosis, body mass index, parity, and genetic ancestry. There were 1274 controls and 1427 cases of any POP and 317 cases of moderate/severe POP. Although none of the analyses reached genome-wide significance (p<5x10-8), we noted variants in several loci that met p<10-6. In race-specific analysis of grade 0 vs 2-3, intronic SNPs in the CPE gene (rs28573326, OR:2.14; 95% CI 1.62-2.83; p = 1.0x10-7) were associated with POP in AAs, and SNPs in the gene AL132709.5 (rs1950626, OR:2.96; 95% CI 1.96-4.48, p = 2.6x10-7) were associated with POP in HPs. Inverse variance fixed-effect meta-analysis of the race-specific results showed suggestive signals for SNPs in the DPP6 gene (rs11243354, OR:1.36; p = 4.2x10-7) in the grade 0 vs 1-3 analyses and for SNPs around PGBD5 (rs740494, OR:2.17; p = 8.6x10-7) and SHC3 (rs2209875, OR:0.60; p = 9.3x10-7) in the grade 0 vs 2-3 analyses. While we did not identify genome-wide significant findings, we document several SNPs reaching suggestive statistical significance. Further interrogation of POP in larger minority samples is warranted.
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Affiliation(s)
- Ayush Giri
- Institute for Medicine and Public Health, Vanderbilt Epidemiology Center, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Jennifer M. Wu
- Department of Obstetrics and Gynecology, Center for Women’s Health Research, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Renee M. Ward
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Katherine E. Hartmann
- Institute for Medicine and Public Health, Vanderbilt Epidemiology Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Amy J. Park
- Department of Obstetrics and Gynecology and Urology, Georgetown University Medical Center, Washington, DC, United States of America
| | - Kari E. North
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Mariaelisa Graff
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Robert B. Wallace
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Gihan Bareh
- Department of Obstetrics and Gynecology, Loma Linda University, Loma Linda, California, United States of America
| | - Lihong Qi
- Department of Public Health Sciences, University of California, Davis, California, United States of America
| | - Mary J. O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, Florida, United States of America
| | - Alexander P. Reiner
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Todd L. Edwards
- Institute for Medicine and Public Health, Vanderbilt Epidemiology Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Digna R. Velez Edwards
- Institute for Medicine and Public Health, Vanderbilt Epidemiology Center, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee, United States of America
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13
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Urban N, Hawley S, Janes H, Karlan BY, Berg CD, Drescher CW, Manson JE, Palomares MR, Daly MB, Wactawski-Wende J, O'Sullivan MJ, Thorpe J, Robinson RD, Lane D, Li CI, Anderson GL. Identifying post-menopausal women at elevated risk for epithelial ovarian cancer. Gynecol Oncol 2015; 139:253-60. [PMID: 26343159 PMCID: PMC4664187 DOI: 10.1016/j.ygyno.2015.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/26/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We developed and validated a hybrid risk classifier combining serum markers and epidemiologic risk factors to identify post-menopausal women at elevated risk for invasive fallopian tube, primary peritoneal, and ovarian epithelial carcinoma. METHODS To select epidemiologic risk factors for use in the classifier, Cox proportional hazards analyses were conducted using 74,786 Women's Health Initiative (WHI) Observational Study (OS) participants. To construct a combination classifier, 210 WHI OS cases and 536 matched controls with serum marker measurements were analyzed; validation employed 143 cases and 725 matched controls from the WHI Clinical Trial (CT) with similar data. RESULTS Analyses identified a combination risk classifier composed of two elevated-risk groups: 1) women with CA125 or HE4 exceeding a 98% specificity threshold; and 2) women with intact fallopian tubes, prior use of menopausal hormone therapy for at least two years, and either a first degree relative with breast or ovarian cancer or a personal history of breast cancer. In the WHI OS population, it classified 13% of women as elevated risk, identifying 30% of ovarian cancers diagnosed up to 7.8years post-enrollment (Hazard Ratio [HR]=2.6, p<0.001). In the WHI CT validation population, it classified 8% of women as elevated risk, identifying 31% of cancers diagnosed within 7years of enrollment (HR=4.6, p<0.001). CONCLUSION CA125 and HE4 contributed significantly to a risk prediction classifier combining serum markers with epidemiologic risk factors. The hybrid risk classifier may be useful to identify post-menopausal women who would benefit from timely surgical intervention to prevent epithelial ovarian cancer.
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Affiliation(s)
- Nicole Urban
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States.
| | - Sarah Hawley
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Holly Janes
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Beth Y Karlan
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | | | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Melanie R Palomares
- Cancer Prevention, Inc., Las Vegas NV and Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mary B Daly
- Fox Chase Cancer Center, Philadelphia PA, United States
| | | | | | - Jason Thorpe
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Randal D Robinson
- University of Texas Health Science Center, San Antonio TX, United States
| | - Dorothy Lane
- Stony Brook University, Stony Brook, NY, United States
| | - Christopher I Li
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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14
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Reijmer YD, Schultz AP, Leemans A, O'Sullivan MJ, Gurol ME, Sperling R, Greenberg SM, Viswanathan A, Hedden T. Decoupling of structural and functional brain connectivity in older adults with white matter hyperintensities. Neuroimage 2015; 117:222-9. [PMID: 26025290 DOI: 10.1016/j.neuroimage.2015.05.054] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/30/2015] [Accepted: 05/09/2015] [Indexed: 12/23/2022] Open
Abstract
Age-related impairments in the default network (DN) have been related to disruptions in connecting white matter tracts. We hypothesized that the local correlation between DN structural and functional connectivity is negatively affected in the presence of global white matter injury. In 125 clinically normal older adults, we tested whether the relationship between structural connectivity (via diffusion imaging tractography) and functional connectivity (via resting-state functional MRI) of the posterior cingulate cortex (PCC) and medial prefrontal frontal cortex (MPFC) of the DN was altered in the presence of white matter hyperintensities (WMH). A significant correlation was observed between microstructural properties of the cingulum bundle and MPFC-PCC functional connectivity in individuals with low WMH load, but not with high WMH load. No correlation was observed between PCC-MPFC functional connectivity and microstructure of the inferior longitudinal fasciculus, a tract not passing through the PCC or MPFC. Decoupling of connectivity, measured as the absolute difference between structural and functional connectivity, in the high WMH group was related to poorer executive functioning and memory performance. These results suggest that such decoupling may reflect reorganization of functional networks in response to global white matter pathology and may provide an early marker of clinically relevant network alterations.
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Affiliation(s)
- Y D Reijmer
- Dept. of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - A P Schultz
- Dept. of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - A Leemans
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M J O'Sullivan
- Dept. of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - M E Gurol
- Dept. of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Sperling
- Dept. of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Dept. of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA; Dept. of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - S M Greenberg
- Dept. of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A Viswanathan
- Dept. of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T Hedden
- Dept. of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
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15
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Quinn EM, Fleming C, O'Sullivan MJ. Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy. Ir J Med Sci 2015; 185:383-92. [PMID: 25971465 DOI: 10.1007/s11845-015-1307-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND/AIMS Adjuvant endocrine therapy for at least 5 years improves oncological outcomes in oestrogen receptor-positive breast cancer. Adherence rates to prescribed endocrine therapy are low and the search for modifiable causes of this continues. The aim of this study was to assess adherence rates in an Irish cohort of breast cancer patients prescribed adjuvant endocrine therapy and to assess modifiable factors associated with suboptimal adherence. METHODS A cross-sectional anonymous survey was performed on 261 patients currently prescribed endocrine therapy. Data were collected regarding demographics, treatment, social and emotional factors and medication side effects. Each patient completed a medication adherence score and provided information about discontinuation of therapy and reasons for same. RESULTS Only 67.8 % of patients assessed demonstrated complete medication adherence on the medication adherence scale. Twenty-nine patients (10.9 %) permanently stopped taking their prescribed endocrine therapy. Suboptimal adherence was more likely in younger patients (p < 0.001), those in employment (p = 0.005), those who experienced side effects (p = 0.006), those who perceived themselves to have low levels of emotional support (p < 0.001) and those who use the internet to read about their illness (p = 0.003). CONCLUSIONS Endocrine therapy adherence is suboptimal in almost one-third of patients in our cohort. Appropriate assessment and management of side effects and negative emotions, combined with direction of patients to accurate internet sources of information, could help improve endocrine therapy adherence in women with early-stage breast cancer.
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Affiliation(s)
- E M Quinn
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland.
| | - C Fleming
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
| | - M J O'Sullivan
- Department of Breast Surgery, Cork University Hospital, Cork, Ireland
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16
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Horton AL, Lai Y, Rouse DJ, Spong CY, Leveno KJ, Varner MW, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O'Sullivan MJ, Hankins GDV, Caritis SN. Effect of magnesium sulfate administration for neuroprotection on latency in women with preterm premature rupture of membranes. Am J Perinatol 2015; 32:387-92. [PMID: 25241107 PMCID: PMC4369158 DOI: 10.1055/s-0034-1387930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aims to evaluate whether magnesium sulfate administration for neuroprotection prolongs latency in women with preterm premature rupture of membranes (PPROM) between 24 and 31(6/7) weeks' gestation. STUDY DESIGN This is a secondary analysis of a randomized controlled trial of magnesium sulfate for prevention of cerebral palsy. Gravid women with a singleton pregnancy between 24 and 31(6/7) weeks' gestation with PPROM without evidence of labor were randomized to receive magnesium sulfate, administered intravenously as a 6-g bolus followed by a constant infusion of 2 g per hour up to 12 hours, or placebo. Maternal outcomes for this analysis were delivery in less than 48 hours and in less than 7 days from randomization. Neonatal outcomes included a composite of respiratory distress syndrome, interventricular hemorrhage grades 3 or 4, periventricular leukomalacia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. RESULTS A total of 1,259 women were included. The rate of delivery < 48 hours was not different in the magnesium sulfate and the placebo groups (22.2 and 20.7%, p = 0.51). Delivery < 7 days was similar between groups (55.4 and 51.4%, p = 0.16). Median latency was also similar between groups (median [interquartile range], 6.0 days [range, 2.4-13.8 days] and 6.6 days [range, 2.4-15.1 days], p = 0.29). Composite neonatal outcomes did not differ between groups. CONCLUSION Magnesium sulfate administration given for neuroprotection in women with a singleton gestation with PPROM and without labor before 32 weeks does not impact latency.
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Affiliation(s)
- Amanda L Horton
- Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, Illinois
| | - Yinglei Lai
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, District of Columbia
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Catherine Y Spong
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson University and Drexel University, Philadelphia, Pennsylvania
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas
| | - Fergal D Malone
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Mary J O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, Florida
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
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17
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Graves SW, Esplin MS, McGee P, Rouse DJ, Leveno KJ, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O'Sullivan MJ, Peaceman AM, Hankins GDV, Dudley DJ, Caritis SN. Association of cord blood digitalis-like factor and necrotizing enterocolitis. Am J Obstet Gynecol 2014; 210:328.e1-328.e5. [PMID: 24215859 DOI: 10.1016/j.ajog.2013.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/30/2013] [Accepted: 11/04/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Endogenous digoxin-like factor (EDLF) has been linked to vasoconstriction, altered membrane transport, and apoptosis. Our objective was to determine whether increased EDLF in the cord sera of preterm infants was associated with an increased incidence of necrotizing enterocolitis (NEC). STUDY DESIGN Cord sera from pregnant women enrolled in a randomized trial of MgSO4 for fetal neuroprotection were analyzed for EDLF using a red cell Rb(+) uptake assay in which the inhibition of sodium pump-mediated Rb(+) transport was used as a functional assay of EDLF. Specimens were assayed blinded to neonatal outcome. Cases (NEC, n = 25) and controls (neonates not developing stage 2 or 3 NEC, n = 24) were matched by study center and gestational age. None of the women had preeclampsia. Cases and controls were compared using the Wilcoxon test for continuous and the Fisher exact test for categorical variables. A conditional logistic regression analysis was used to assess the odds of case vs control by EDLF level. RESULTS Cases and controls were not significantly different for gestational age, race, maternal steroid use, premature rupture of membranes, or MgSO4 treatment. In logistic models adjusted for treatment group, race, premature rupture of membranes, and gestational age, cord sera EDLF was significantly associated with development of NEC (P = .023). CONCLUSION These data demonstrated an association between cord sera EDLF and NEC.
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Affiliation(s)
- Steven W Graves
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT.
| | - Michael S Esplin
- Departments of Obstetrics and Gynecology, Utah Health Science Center, Salt Lake City, UT
| | - Paula McGee
- Biostatistics Center, George Washington University, Washington, DC
| | - Dwight J Rouse
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | | | - Brian M Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, and University of Tennessee, Memphis, TN
| | - Jay D Iams
- The Ohio State University College of Medicine, Columbus, OH
| | - Ronald J Wapner
- Jefferson Medical College, Thomas Jefferson University, and Drexel University College of Medicine, Philadelphia, PA
| | - Yoram Sorokin
- Wayne State University School of Medicine, Detroit, MI
| | - John M Thorp
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Susan M Ramin
- University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Fergal D Malone
- College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - Alan M Peaceman
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Donald J Dudley
- University of Texas at San Antonio School of Medicine, San Antonio, TX
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18
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Grobman WA, Lai Y, Rouse DJ, Spong CY, Varner MW, Mercer BM, Leveno KJ, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O'Sullivan MJ, Hankins GD, Caritis SN. The association of cerebral palsy and death with small-for-gestational-age birthweight in preterm neonates by individualized and population-based percentiles. Am J Obstet Gynecol 2013; 209:340.e1-5. [PMID: 23770470 DOI: 10.1016/j.ajog.2013.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether an individualized growth standard (IS) improves the identification of preterm small-for-gestational-age (SGA) neonates at risk of developing moderate/severe cerebral palsy (CP) or death. STUDY DESIGN This study was a secondary analysis of data from a randomized trial of MgSO4 for the prevention of CP or death among anticipated preterm births. Singleton nonanomalous liveborns delivered before 34 weeks' were classified as SGA (less than the 10th percentile for their gestational age) by a population standard (PS) or an IS (incorporating maternal age, height, weight, parity, race/ethnicity, and neonatal sex). The primary outcome was the prediction of moderate or severe CP or death by age 2 years. RESULTS Of 1588 eligible newborns, 143 (9.4%) experienced CP (n = 33) or death (n = 110). Forty-four (2.8%) were SGA by the PS and 364 (22.9%) by the IS. All PS-SGA newborns also were identified as IS-SGA. SGA newborns by either standard had a similarly increased risk of CP or death (PS: relative risk [RR], 2.4, 95% confidence interval [CI], 1.3-4.3 vs IS: RR, 1.8, 95% CI, 1.3-2.5, respectively). The similarity of RRs remained after stratification by the MgSO4 treatment group. The IS was more sensitive (36% vs 6%, P < .001) but less specific (78% vs 98%, P < .001) for CP or death. The receiver operating characteristic curve analysis revealed a statistically lower area under the curve for the PS, although the ability of either method to predict which neonates would subsequently develop CP or death was poor (PS: 0.55, 95% CI, 0.49-0.60 vs IS: 0.59, 95% CI, 0.54-0.64, P < .001). CONCLUSION An individualized SGA growth standard does not improve the association with, or prediction of, CP or death by age 2 years.
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Gilbert SA, Grobman WA, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Wapner RJ, Sorokin Y, O'Sullivan MJ, Sibai BM, Thorp JM, Ramin SM, Mercer BM. Cost-effectiveness of trial of labor after previous cesarean in a minimally biased cohort. Am J Perinatol 2013; 30:11-20. [PMID: 23292916 PMCID: PMC4049080 DOI: 10.1055/s-0032-1333206] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC). STUDY DESIGN A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature. RESULTS The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more. CONCLUSION A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.
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Affiliation(s)
- Sharon A Gilbert
- The George Washington University Biostatistics Center, Washington, District of Columbia, USA.
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20
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Cotter AM, Brookfield KF, Duthely LM, Gonzalez Quintero VH, Potter JE, O'Sullivan MJ. Duration of membrane rupture and risk of perinatal transmission of HIV-1 in the era of combination antiretroviral therapy. Am J Obstet Gynecol 2012; 207:482.e1-5. [PMID: 23103331 DOI: 10.1016/j.ajog.2012.10.862] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 09/13/2012] [Accepted: 10/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether the duration of membrane rupture of 4 or more hours is a significant risk factor for perinatal transmission of human immunodeficiency virus (HIV) in the era of combination antiretroviral therapy (ART). STUDY DESIGN This was a prospective cohort study of 717 HIV-infected pregnant women-infant pairs with a delivery viral load available who received prenatal care and delivered at our institution during the interval 1996-2008. RESULTS The cohort comprised 707 women receiving ART who delivered during this interval. The perinatal transmission rate was 1% in women with membranes ruptured for less than 4 hours and 1.9% when ruptured for 4 or more hours. For 493 women with a delivery viral load less than 1000 copies/mL receiving combination ART in pregnancy, there were no cases of perinatal transmission identified up to 25 hours of membrane rupture. Logistic regression demonstrated only a viral load above 10,000 copies/mL as an independent risk factor for perinatal transmission. CONCLUSION Duration of membrane rupture of 4 or more hours is not a risk factor for perinatal transmission of HIV in women with a viral load less than 1000 copies/mL receiving combination ART.
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21
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Costantine MM, Clark EAS, Lai Y, Rouse DJ, Spong CY, Mercer BM, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter M, Miodovnik M, O'Sullivan MJ, Peaceman AM, Caritis SN. Association of polymorphisms in neuroprotection and oxidative stress genes and neurodevelopmental outcomes after preterm birth. Obstet Gynecol 2012; 120:542-50. [PMID: 22914463 PMCID: PMC3904537 DOI: 10.1097/aog.0b013e318265f232] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To estimate the associations between polymorphisms in neuronal homeostasis, neuroprotection, and oxidative stress candidate genes and neurodevelopmental disability. METHODS This was a nested case-control analysis of a randomized trial of magnesium sulfate administered to women at imminent risk for early (before 32 weeks) preterm birth for the prevention of death or cerebral palsy in their offspring. We evaluated 21 single-nucleotide polymorphisms (SNPs) in 17 genes associated with neuronal homeostasis, neuroprotection, or oxidative stress in umbilical cord blood. Cases included infant deaths (n=43) and children with cerebral palsy (n=24), mental delay (Bayley Mental Developmental Index less than 70; n=109), or psychomotor delay (Bayley Psychomotor Developmental Index less than 70; n=91) diagnosed. Controls were race-matched and sex-matched children with normal neurodevelopment. Associations between each SNP and each outcome were assessed in logistic regression models assuming an additive genetic pattern, conditional on maternal race and infant sex, and adjusting for study drug assignment, gestational age at birth, and maternal education. RESULTS The odds of cerebral palsy were increased more than 2.5 times for each copy of the minor allele of vasoactive intestinal polypeptipe (VIP, rs17083008) (adjusted odds ratio 2.67, 95% confidence interval 1.09-6.55, P=.03) and 4.5 times for each copy of the minor allele of N-methyl-D-aspartate receptor subunit 3A (GRIN3A, rs3739722) (adjusted odds ratio 4.67, 95% CI 1.36-16.01, P=.01). The association between the advanced glycosylation end product-specific receptor (AGER, rs3134945) SNP and mental delay was modulated by study drug allocation (P=.02). CONCLUSION Vasoactive intestinal polypeptipe and GRIN3A SNPs may be associated with cerebral palsy at age 2 in children born preterm.
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MESH Headings
- Case-Control Studies
- Cerebral Palsy/genetics
- Child, Preschool
- Developmental Disabilities/genetics
- Female
- Genetic Markers
- Homeostasis/genetics
- Humans
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/genetics
- Infant, Premature, Diseases/mortality
- Intellectual Disability/genetics
- Logistic Models
- Male
- Oxidative Stress/genetics
- Polymorphism, Single Nucleotide
- Psychological Tests
- Psychomotor Disorders/genetics
- Receptor for Advanced Glycation End Products
- Receptors, Immunologic/genetics
- Receptors, N-Methyl-D-Aspartate/genetics
- Vasoactive Intestinal Peptide/genetics
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Affiliation(s)
- Maged M Costantine
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, USA.
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22
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Johnson LH, Mapp DC, Rouse DJ, Spong CY, Mercer BM, Leveno KJ, Varner MW, Iams JD, Sorokin Y, Ramin SM, Miodovnik M, O'Sullivan MJ, Peaceman AM, Caritis SN. Association of cord blood magnesium concentration and neonatal resuscitation. J Pediatr 2012; 160:573-577.e1. [PMID: 22056282 PMCID: PMC3998513 DOI: 10.1016/j.jpeds.2011.09.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 08/08/2011] [Accepted: 09/06/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To assess the relationship between umbilical cord blood magnesium concentration and level of delivery room resuscitation received by neonates. STUDY DESIGN This was a secondary analysis of a controlled fetal neuroprotection trial that enrolled women at imminent risk for delivery between 24 and 31 weeks' gestation and randomly allocated them to receive either intravenous magnesium sulfate or placebo. The cohort included 1507 infants with data available on total cord blood Mg concentration and delivery room resuscitation. Multivariate logistic regression was used to estimate the association between cord blood Mg concentration and highest level of delivery room resuscitation, using the following hierarchy: none, oxygen only, bag-mask ventilation with oxygen, intubation, and chest compressions. RESULTS There was no relationship between cord blood Mg and delivery room resuscitation (OR, 0.92 for each 1.0-mEq/L increase in Mg; 95% CI, 0.83-1.03). Maternal general anesthesia was associated with increased neonatal resuscitation (OR, 2.51; 95% CI, 1.72-3.68). Each 1-week increase in gestational age at birth was associated with decreased neonatal resuscitation (OR, 0.63; 95% CI, 0.60-0.66). CONCLUSION Cord blood Mg concentration does not correlate with the level of delivery room resuscitation of infants exposed to magnesium sulfate for fetal neuroprotection.
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Affiliation(s)
- Lynn H Johnson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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23
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Gilbert SA, Grobman WA, Landon MB, Spong CY, Rouse DJ, Leveno KJ, Varner MW, Caritis SN, Meis PJ, Sorokin Y, Carpenter M, O'Sullivan MJ, Sibai BM, Thorp JM, Ramin SM, Mercer BM. Elective repeat cesarean delivery compared with spontaneous trial of labor after a prior cesarean delivery: a propensity score analysis. Am J Obstet Gynecol 2012; 206:311.e1-9. [PMID: 22464069 DOI: 10.1016/j.ajog.2012.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/04/2012] [Accepted: 02/06/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine outcomes, after the use of propensity score techniques, to create balanced groups according to whether a woman undergoes elective repeat cesarean delivery (ERCD) or trial of labor (TOL). STUDY DESIGN Women who were eligible for a TOL with 1 previous low transverse incision were categorized according to whether they underwent an ERCD or TOL. A propensity score technique was used to develop ERCD and TOL groups with comparable baseline characteristics. Outcomes were assessed with conditional logistic regression. RESULTS The rates of endometritis, operative injury, respiratory distress syndrome, and newborn infant infection were lower and the rates of hysterectomy and wound complication were higher in the ERCD group. CONCLUSION Propensity score techniques can be used to generate comparable ERCD and TOL groups. Some types of maternal morbidity (such as hysterectomy) are higher; other types (such as operative injury) are lower in the ERCD group. Although the absolute risk is low, neonatal morbidity appears to be lower in the ERCD group.
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Affiliation(s)
- Sharon A Gilbert
- The George Washington University Biostatistics Center, Washington, DC, USA
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24
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McDowell DT, Nguyen T, O'Sullivan MJ, Corbally M. When is a scrotal swelling not a scrotal swelling? Eur J Pediatr Surg 2011; 21:342-3. [PMID: 21678241 DOI: 10.1055/s-0031-1275750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- D T McDowell
- Our Lady's Children Hospital, Paediatric Surgery, Dublin, Ireland
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25
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Costantine MM, Weiner SJ, Rouse DJ, Hirtz DG, Varner MW, Spong CY, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, O'Sullivan MJ, Peaceman AM, Simhan HN. Umbilical cord blood biomarkers of neurologic injury and the risk of cerebral palsy or infant death. Int J Dev Neurosci 2011; 29:917-22. [PMID: 21736934 DOI: 10.1016/j.ijdevneu.2011.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 06/20/2011] [Accepted: 06/20/2011] [Indexed: 11/17/2022] Open
Abstract
To evaluate the association between cerebral palsy (CP) or infant death and putative cord blood biomarkers of neurologic injury, we performed a nested case-control secondary analysis of a multicenter randomized trial of magnesium sulfate (MgSO(4)) versus placebo to prevent CP or death among offspring of women with anticipated delivery from 24 to 31 weeks' gestation. Cases were infants who died by 1 year (n=25) or developed CP (n=16), and were matched 1:2 to a control group (n=82) that survived without developing CP. Umbilical cord sera concentrations of S100B, neuron-specific enolase (NSE) and the total soluble form of the receptor for advanced glycation end-products (sRAGE) were measured by ELISA in duplicates. Maternal characteristics were similar between the 2 groups. Cases were born at a lower gestational age (GA) and had lower birth weight compared with controls. There were no differences in concentrations of the three biomarkers and the composite outcome of CP or infant death. However, S100B was higher (median 847.3 vs. 495.7 pg/ml; P=0.03) in infants who had CP and total sRAGE was lower (median 1259.3 vs. 1813.1 pg/ml; P=0.02) in those who died compared with the control group. When corrected for delivery GA and treatment group, both differences lost statistical significance. In conclusion, cord blood S100B level may be associated with CP, but this association was not significant after controlling for GA and MgSO(4) treatment.
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Affiliation(s)
- Maged M Costantine
- Department of Obstetrics and Gynecology at the University of Texas Medical Branch, Galveston, TX, USA.
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26
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Mertz HL, Mele L, Spong CY, Dudley DJ, Wapner RJ, Iams JD, Sorokin Y, Peaceman A, Leveno KJ, Caritis SN, Miodovnik M, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter M, Rouse DJ, Sibai B. Placental endothelial nitric oxide synthase in multiple and single dose betamethasone exposed pregnancies. Am J Obstet Gynecol 2011; 204:545.e11-6. [PMID: 21529755 DOI: 10.1016/j.ajog.2011.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 01/13/2011] [Accepted: 02/04/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare endothelial nitric oxide synthase expression and capillary density (CDS) in placentas exposed to single or multiple courses of betamethasone. STUDY DESIGN Placental specimens exposed to single vs repeat courses of betamethasone were analyzed through immunohistochemistry and digital image quantification for endothelial nitric oxide synthase and CD34. Quantified endothelial nitric oxide synthase staining, calculated capillary density, ratio of endothelial nitric oxide synthase to capillary density, and clinical characteristics were compared. Linear regression was performed with these as dependent variables. RESULTS Mean and maximum capillary density were increased (P = .013 and .005) and the ratio of endothelial nitric oxide synthase to capillary density decreased (P = .016) in specimens exposed to 4 courses of betamethasone compared with 1 to 3 courses. Exposure to 4 courses of betamethasone was associated with increased capillary density, but not with endothelial nitric oxide synthase expression. CONCLUSION Exposure to 4 courses of betamethasone is associated with increased placental capillary density. The placental effects of multiple courses of betamethasone are unrelated to endothelial nitric oxide synthase expression.
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Affiliation(s)
- Heather L Mertz
- Departments of Obstetrics and Gynecology, Wake Forest Health Sciences, Winston-Salem, NC, USA
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27
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Ramirez MM, Gilbert S, Landon MB, Rouse DJ, Spong CY, Varner MW, Caritis SN, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Mercer BM. Mode of delivery in women with antepartum fetal death and prior cesarean delivery. Am J Perinatol 2010; 27:825-30. [PMID: 20486068 PMCID: PMC3272299 DOI: 10.1055/s-0030-1254548] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We describe obstetric outcomes in a group of patients with prior cesarean delivery (CD) presenting with an intrauterine fetal demise (IUFD). A secondary analysis of an observational study of women with prior CD was performed. All antepartum singleton pregnancies with a prior CD and IUFD ≥20 weeks' gestation or 500 g were evaluated. Two hundred nine patients met inclusion criteria for analysis. The mean gestational age ± standard deviation at delivery was 31.3 ± 6.5 weeks. The trial of labor rate was 75.6% (158/209), and the vaginal birth after cesarean (VBAC) success rate was 86.7%. Labor induction or augmentation occurred in 83.3% of attempted VBAC. Uterine rupture occurred in five women (2.4%), and in 3.4% of those being induced but none of these required hysterectomy. Women with a history of previous CD and an IUFD often undergo trial of labor with a high VBAC success rate. Uterine rupture complicates 2.4% of such cases.
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Affiliation(s)
- Mildred M Ramirez
- Departments of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA. Mildred.M.Ramirez @uth.tmc.edu
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28
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Gyamfi C, Mele L, Wapner RJ, Spong CY, Peaceman A, Sorokin Y, Dudley DJ, Johnson F, Leveno KJ, Caritis SN, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter M, Rouse DJ, Miodovnik M, Sibai B. The effect of plurality and obesity on betamethasone concentrations in women at risk for preterm delivery. Am J Obstet Gynecol 2010; 203:219.e1-5. [PMID: 20579955 PMCID: PMC3214971 DOI: 10.1016/j.ajog.2010.04.047] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 03/08/2010] [Accepted: 04/29/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Antenatal corticosteroids (ACS) decrease respiratory distress syndrome in singleton gestations. Twin data are less clear. Obesity and body mass index (BMI) also affect medication distribution volume. We evaluated whether maternal or neonatal cord betamethasone concentrations differed in twin gestations or obese patients. STUDY DESIGN Participants receiving betamethasone in a randomized controlled trial of weekly ACS were identified. We analyzed maternal delivery and cord serum betamethasone concentrations comparing singletons with twins and obese (BMI > or =30 kg/m(2)) with nonobese women. RESULTS Fifty-five maternal and 45 cord blood samples were available. Unadjusted median maternal serum concentrations appeared paradoxically higher in both twin gestations and the obese. However, after controlling for confounders, there were no differences in betamethasone concentrations in maternal serum or cord blood between singletons and twins (P = .61 vs P = .14) or nonobese and obese women (P = .67 vs .12). CONCLUSION Maternal and umbilical cord blood serum betamethasone concentrations are not different in twin gestations or obese women.
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Affiliation(s)
- Cynthia Gyamfi
- Department of Obstetrics and Gynecology at Columbia University, New York, NY, USA.
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29
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Manuck TA, Price TM, Thom E, Meis PJ, Dombrowski MP, Sibai B, Spong CY, Rouse DJ, Iams JD, Simhan HN, O'Sullivan MJ, Miodovnik M, Leveno KJ, Conway D, Wapner RJ, Carpenter M, Mercer B, Ramin SM, Thorp JM, Peaceman AM. Absence of mitochondrial progesterone receptor polymorphisms in women with spontaneous preterm birth. Reprod Sci 2010; 17:913-6. [PMID: 20693499 DOI: 10.1177/1933719110374365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The truncated mitochondrial progesterone receptor (PR-M) is homologous to nuclear PRs with the exception of an amino terminus hydrophobic membrane localization sequence, which localizes PR-M to mitochondria. Given the matrilineal inheritance of both spontaneous preterm birth (SPTB) and the mitochondrial genome, we hypothesized that (a) PR-M is polymorphic and (b) PR-M localization sequence polymorphisms could result in variable progesterone-mitochondrial effects and variable responsiveness to progesterone prophylaxis. METHODS Secondary analysis of DNA from women enrolled in a multicenter, prospective, study of 17 alpha-hydroxyprogesterone caproate (17OHPC) versus placebo for the prevention of recurrent SPTB. DNA was extracted from stored saliva. RESULTS The PR-M localization sequence was sequenced on 344 patients. Sequences were compared with the previously published 48 base-pair sequence, and all were identical. CONCLUSIONS We did not detect genetic variation in the mitochondrial localization sequence of the truncated PR-M in a group of women at high risk for SPTB.
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Affiliation(s)
- Tracy A Manuck
- Eunice Kennedy Shriver NICHD MFMU Network, Bethesda, MD, USA.
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30
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Church MW, Wapner RJ, Mele LM, Johnson F, Dudley DJ, Spong CY, Peaceman AM, Moawad AH, O'Sullivan MJ, Miodovnik M. Repeated courses of antenatal corticosteroids: are there effects on the infant's auditory brainstem responses? Neurotoxicol Teratol 2010; 32:605-10. [PMID: 20553856 DOI: 10.1016/j.ntt.2010.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 05/04/2010] [Accepted: 05/20/2010] [Indexed: 11/17/2022]
Abstract
Our objective was to assess the effects of repeated antenatal corticosteroid treatments on the neonatal auditory brainstem response (ABR), a sensitive measure of neonatal brain maturity and auditory function. To achieve this, we performed and blindly evaluated neonatal ABRs on a subset of infants delivering within a multicenter randomized placebo-controlled clinical trial comparing single versus repeated courses of antenatal corticosteroid treatments for women at 23-31 weeks gestation who remained at increased risk for preterm birth. The women were randomly assigned to either the single or the repeated antenatal corticosteroid treatment group. Women in the repeated antenatal corticosteroid group received weekly antenatal corticosteroid treatments until 34 weeks gestation or until they reached a study-determined limited number of courses, whereas women in the single antenatal corticosteroid group received an initial course of corticosteroid followed by weekly placebo injections. We performed ABR testing on their infants prior to discharge. The latencies of waves I, III and V and the peak-to-trough amplitudes of waves I and V were compared between those in the single (n=27) and repeated antenatal corticosteroid treatment (n=24) groups. The majority of repeated antenatal corticosteroid infants (20 of 24) were exposed to ≥ 4 antenatal corticosteroid treatments. Even though gestational age was similar between our subset of single and repeated antenatal corticosteroid treatment groups, infant birth weight and length and head circumference were significantly smaller in the repeated antenatal corticosteroid group (p <0.05). Despite these differences in birth sizes, there were no significant group differences in the ABR wave latencies or amplitudes. We concluded that our repeated antenatal corticosteroid treatments, in comparison to a single treatment, did not significantly benefit or harm the neonatal ABR despite significant effects on birth size.
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Affiliation(s)
- Michael W Church
- Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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31
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Hashima JN, Lai Y, Wapner RJ, Sorokin Y, Dudley DJ, Peaceman A, Spong CY, Iams JD, Leveno KJ, Harper M, Caritis SN, Varner M, Miodovnik M, Mercer BM, Thorp JM, O'Sullivan MJ, Ramin SM, Carpenter M, Rouse DJ, Sibai B. The effect of maternal body mass index on neonatal outcome in women receiving a single course of antenatal corticosteroids. Am J Obstet Gynecol 2010; 202:263.e1-5. [PMID: 20022589 DOI: 10.1016/j.ajog.2009.10.859] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 07/24/2009] [Accepted: 10/16/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to determine the effect of maternal body mass index on the incidence of neonatal prematurity morbidities in those who receive corticosteroids. STUDY DESIGN This was a secondary analysis of a trial of corticosteroids in women at risk for preterm birth. Women receiving a single course of corticosteroids were classified by their prepregnancy body mass index (<25 and > or = 25) and compared on a composite outcome comprised of several neonatal morbidities and on each individual outcome. RESULTS Of 183 eligible women, 96 (52.5%) had a body mass index of <25 and 87 (47.5%) had a body mass index of > or = 25. The composite outcome occurred more frequently in the body mass index of > or = 2 5 group (28.7%), compared with those with a body mass index of <25 (18.8%), although this was not statistically significant (odds ratio, 1.75; 95% confidence interval, 0.83-3.72). Body mass index was not associated with outcomes after adjusting for confounding. CONCLUSION Maternal body mass index did not affect neonatal prematurity morbidities in those receiving corticosteroids.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Adult
- Betamethasone/therapeutic use
- Body Mass Index
- Bronchopulmonary Dysplasia/epidemiology
- Bronchopulmonary Dysplasia/prevention & control
- Dexamethasone/therapeutic use
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/prevention & control
- Female
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/prevention & control
- Injections, Intramuscular
- Intracranial Hemorrhages/epidemiology
- Intracranial Hemorrhages/prevention & control
- Leukomalacia, Periventricular/epidemiology
- Leukomalacia, Periventricular/prevention & control
- Obesity/epidemiology
- Pregnancy
- Respiratory Distress Syndrome, Newborn/epidemiology
- Respiratory Distress Syndrome, Newborn/prevention & control
- Retinopathy of Prematurity/epidemiology
- Retinopathy of Prematurity/prevention & control
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Affiliation(s)
- Jason N Hashima
- Department of Obstetrics, Oregon Health & Science University, Portland, OR, USA.
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Li R, O'Sullivan MJ, Robinson J, Safford MM, Curb D, Johnson KC. Family history of myocardial infarction predicts incident coronary heart disease in postmenopausal women with diabetes: the Women's Health Initiative Observational Study. Diabetes Metab Res Rev 2009; 25:725-32. [PMID: 19780066 PMCID: PMC4478605 DOI: 10.1002/dmrr.1010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Diabetes is a risk factor for coronary heart disease (CHD) but CHD does not occur in all diabetic individuals. The goal of this study was to assess the relationship between family history of myocardial infarction (MI) and incident CHD in diabetic postmenopausal women. METHODS We conducted a prospective cohort study among 2642 diabetic postmenopausal women without CHD at baseline in the Women's Health Initiative Observational Study. Family history was defined as a proband report of MI in first-degree relatives. Incident CHD was defined as non-fatal MI, coronary revascularization, or CHD death. RESULTS During 7.3 ( +/- 1.8) years of follow-up, 14.3% of the participants had incident CHD. The risk of incident CHD was 50% higher (HR = 1.50, 95% CI: 1.20-1.87, p = 0.0003) in those with a family history of an MI in at least one first-degree relative, and 79% higher (HR = 1.79, 95% CI: 1.36-2.35, P < 0.0001) if two or more first-degree relatives had an MI, compared to participants without a family history, after adjustment for covariates. The CHD risk increased with elevated systolic blood pressure (SBP) (HR = 1.01, 95% CI: 1.003-1.02, p = 0.001) but decreased with elevated diastolic BP (HR = 0.98, 95% CI: 0.97-0.999, p = 0.005) and with two or more episodes per week of physical activity (HR = 0.70, 95% CI: 0.52-0.93, p = 0.02). CONCLUSIONS The results suggest that a family history of MI predicts CHD in diabetic postmenopausal women. Close attention should be paid to BP control and physical activity in these women.
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Affiliation(s)
- Rongling Li
- University of Tennessee Health Science Center, Department of Preventive Medicine, Memphis, TN, USA.
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Alexander JM, Leveno KJ, Hauth JC, Landon MB, Gilbert S, Spong CY, Varner MW, Caritis SN, Meis P, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, Sibai BM, Langer O, Gabbe SG. Failed operative vaginal delivery. Obstet Gynecol 2009; 114:1017-1022. [PMID: 20168101 PMCID: PMC3075422 DOI: 10.1097/aog.0b013e3181bbf3be] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare maternal and neonatal outcomes in women undergoing second-stage cesarean delivery after a trial of operative vaginal delivery with those in women undergoing second-stage cesarean delivery without such an attempt. METHODS This study is a secondary analysis of the women who underwent second-stage cesarean delivery. The maternal outcomes examined included blood transfusion, endometritis, wound complication, anesthesia use, and maternal death. Neonatal outcomes examined included umbilical artery pH less than 7.0, Apgar score of 3 or less at 5 minutes, seizures within 24 hours of birth, hypoxic ischemic encephalopathy, stillbirth, skull fracture, and neonatal death. RESULTS Of 3,189 women who underwent second-stage cesarean delivery, operative vaginal delivery was attempted in 640. Labor characteristics were similar in the two groups, with the exception of the admission-to-delivery time and cesarean indication. Those with an attempted operative vaginal delivery were more likely to undergo cesarean delivery for a nonreassuring fetal heart rate tracing (18.0% compared with 13.9%, P=.01), have a wound complication (2.7% compared with 1.0%, odds ratio [OR] 2.65, 95% confidence interval [CI] 1.43-4.91), and require general anesthesia (8.0% compared with 4.1%, OR 2.05, 95% CI 1.44-2.91). Neonatal outcomes, including umbilical artery pH less than 7.0, Apgar score of 3 or less at 5 minutes, and hypoxic ischemic encephalopathy, were more common for those with an attempted operative vaginal delivery. This was not significant when cases with a nonreassuring fetal heart rate tracing were removed. CONCLUSION Cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes in the absence of a nonreassuring fetal heart rate tracing. LEVEL OF EVIDENCE II.
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Affiliation(s)
- James M Alexander
- From the Departments of Obstetrics and Gynecology at the University of Texas Southwestern Medical Center, Dallas, Texas; the University of Alabama at Birmingham, Birmingham, Alabama; the Ohio State University, Columbus, Ohio; the University of Utah, Salt Lake City, Utah; the University of Pittsburgh, Pittsburgh, Pennsylvania; Wake Forest University Health Sciences, Winston-Salem, North Carolina; Thomas Jefferson University, Philadelphia, Pennsylvania; Wayne State University, Detroit, Michigan; the University of Cincinnati, Cincinnati, Ohio; the University of Miami, Miami, Florida; the University of Tennessee, Memphis, Tennessee; the University of Texas Health Science Center at San Antonio, San Antonio, Texas; Vanderbilt University, Nashville, Tennessee; the George Washington University Biostatistics Center, Washington, DC, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Varner MW, Noble WD, Dombrowski M, Sibai B, Rouse DJ, Paul R, Caritis SN, Miodovnik M, Moawad A, Iams JD, Witter F, Romero R, Leveno K, Meis P, Wapner R, Rosen M, Thurnau G, van Dorsten P, O'Sullivan MJ, Conway D. Is there a seasonal variation in the diagnosis of oligohydramnios? J Matern Fetal Neonatal Med 2009; 17:173-7. [PMID: 16152688 DOI: 10.1080/14767050400028691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We hypothesized that oligohydramnios would be diagnosed more frequently in the warm summer months when dehydration might be more common. METHODS The clinical diagnosis of oligohydramnios was extracted from the databases of four completed National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network protocols. These data were stratified by quarter of delivery and compared using Fisher's Exact Test. RESULTS The clinical diagnosis of oligohydramnios was made more frequently in deliveries occurring in the summer months of June, July and August as compared with the remainder of the calendar year (7.2% vs 5.9%, p=0.0178). CONCLUSIONS In these studies the diagnosis of oligohydramnios is made more frequently in those pregnancies delivered during the summer months. Although not proven by this association, maternal dehydration may contribute to this finding.
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Affiliation(s)
- Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City 84132, USA.
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Tita ATN, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, Moawad AH, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009; 360:111-20. [PMID: 19129525 PMCID: PMC2811696 DOI: 10.1056/nejmoa0803267] [Citation(s) in RCA: 551] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes. METHODS We studied a cohort of consecutive patients undergoing repeat cesarean sections performed at 19 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network from 1999 through 2002. Women with viable singleton pregnancies delivered electively (i.e., before the onset of labor and without any recognized indications for delivery before 39 weeks of gestation) were included. The primary outcome was the composite of neonatal death and any of several adverse events, including respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (ICU). RESULTS Of 24,077 repeat cesarean deliveries at term, 13,258 were performed electively; of these, 35.8% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.5% at 38 weeks) and 49.1% at 39 weeks of gestation. One neonatal death occurred. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks. CONCLUSIONS Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.
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Affiliation(s)
- Alan T N Tita
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Alabama at Birmingham, 619 19th St. South, Birmingham, AL 35249, USA.
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Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor? Am J Obstet Gynecol 2009; 200:56.e1-6. [PMID: 18822401 DOI: 10.1016/j.ajog.2008.06.039] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 04/25/2008] [Accepted: 06/12/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL). STUDY DESIGN Using a previously published prediction model, we categorized women with 1 prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach. RESULTS Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P < .001) but not elective repeat cesarean section (ERCS) (P > .05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (relative risk [RR], 2.2; 95% confidence interval [CI], 1.5-3.1) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the 2 groups (RR, 0.8; 95% CI, 0.5-1.2). The results were similar for neonatal morbidity. CONCLUSION A prediction model for VBAC provides information regarding the chance of TOL-related morbidity and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology at Northwestern University, Chicago, IL, USA
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Klebanoff MA, Meis PJ, Dombrowski MP, Zhao Y, Moawad AH, Northen A, Sibai BM, Iams JD, Varner MW, Caritis SN, O'Sullivan MJ, Leveno KJ, Miodovnik M, Conway D, Wapner RJ, Carpenter M, Mercer BM, Ramin SM, Thorp JM, Peaceman AM. Salivary progesterone and estriol among pregnant women treated with 17-alpha-hydroxyprogesterone caproate or placebo. Am J Obstet Gynecol 2008; 199:506.e1-7. [PMID: 18456237 PMCID: PMC2794481 DOI: 10.1016/j.ajog.2008.03.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2007] [Revised: 12/05/2007] [Accepted: 03/03/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objectives of the study was to determine whether salivary progesterone (P) or estriol (E3) concentration at 16-20 weeks' gestation predicts preterm birth or the response to 17alpha-hydroxyprogesterone caproate (17OHPC) and whether 17OHPC treatment affected the trajectory of salivary P and E3 as pregnancy progressed. STUDY DESIGN This was a secondary analysis of a clinical trial of 17OHPC to prevent preterm birth. Baseline saliva was assayed for P and E3. Weekly salivary samples were obtained from 40 women who received 17OHPC and 40 who received placebo in a multicenter randomized trial of 17OHPC to prevent recurrent preterm delivery. RESULTS Both low and high baseline saliva P and E3 were associated with a slightly increased risk of preterm birth. However, 17OHPC prevented preterm birth comparably, regardless of baseline salivary hormone concentrations. 17OHPC did not alter the trajectory of salivary P over pregnancy, but it significantly blunted the rise in salivary E3 as well as the rise in the E3/P ratio. CONCLUSION 17OHPC flattened the trajectory of E3 in the second half of pregnancy, suggesting that the drug influences the fetoplacental unit.
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Affiliation(s)
- Mark A Klebanoff
- National Institute of Child Health and Human Development, Bethesda, MD, USA
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O'Neill A, O'Sullivan MJ, McDermott E. Spontaneous common bile duct rupture in a pregnant female--a rare cause of peritonitis. Eur J Obstet Gynecol Reprod Biol 2008; 142:81. [PMID: 18951689 DOI: 10.1016/j.ejogrb.2008.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 08/09/2008] [Accepted: 09/04/2008] [Indexed: 11/19/2022]
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Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Alexander JM, Harper M, Thorp JM, Ramin SM, Malone FD, Carpenter M, Miodovnik M, Moawad A, O'Sullivan MJ, Peaceman AM, Hankins GDV, Langer O, Caritis SN, Roberts JM. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. N Engl J Med 2008; 359:895-905. [PMID: 18753646 PMCID: PMC2803083 DOI: 10.1056/nejmoa0801187] [Citation(s) in RCA: 522] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Research suggests that fetal exposure to magnesium sulfate before preterm birth might reduce the risk of cerebral palsy. METHODS In this multicenter, placebo-controlled, double-blind trial, we randomly assigned women at imminent risk for delivery between 24 and 31 weeks of gestation to receive magnesium sulfate, administered intravenously as a 6-g bolus followed by a constant infusion of 2 g per hour, or matching placebo. The primary outcome was the composite of stillbirth or infant death by 1 year of corrected age or moderate or severe cerebral palsy at or beyond 2 years of corrected age. RESULTS A total of 2241 women underwent randomization. The baseline characteristics were similar in the two groups. Follow-up was achieved for 95.6% of the children. The rate of the primary outcome was not significantly different in the magnesium sulfate group and the placebo group (11.3% and 11.7%, respectively; relative risk, 0.97; 95% confidence interval [CI], 0.77 to 1.23). However, in a prespecified secondary analysis, moderate or severe cerebral palsy occurred significantly less frequently in the magnesium sulfate group (1.9% vs. 3.5%; relative risk, 0.55; 95% CI, 0.32 to 0.95). The risk of death did not differ significantly between the groups (9.5% vs. 8.5%; relative risk, 1.12; 95% CI, 0.85 to 1.47). No woman had a life-threatening event. CONCLUSIONS Fetal exposure to magnesium sulfate before anticipated early preterm delivery did not reduce the combined risk of moderate or severe cerebral palsy or death, although the rate of cerebral palsy was reduced among survivors. (ClinicalTrials.gov number, NCT00014989.)
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Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Prediction of uterine rupture associated with attempted vaginal birth after cesarean delivery. Am J Obstet Gynecol 2008; 199:30.e1-5. [PMID: 18439555 DOI: 10.1016/j.ajog.2008.03.039] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 11/29/2007] [Accepted: 03/17/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to develop a model that predicts individual-specific risk of uterine rupture during an attempted vaginal birth after cesarean delivery. STUDY DESIGN Women with 1 previous low-transverse cesarean delivery who underwent a trial of labor with a term singleton were identified in a concurrently collected database of deliveries that occurred at 19 academic centers during a 4-year period. We analyzed different classification techniques in an effort to develop an accurate prediction model for uterine rupture. RESULTS Of the 11,855 women who were available for analysis, 83 women (0.7%) had had a uterine rupture. The optimal final prediction model, which was based on a logistic regression, included 2 variables: any previous vaginal delivery (odds ratio, 0.44; 95% CI, 0.27-0.71) and induction of labor (odds ratio, 1.73; 95% CI, 1.11-2.69). This model, with a c-statistic of 0.627, had poor discriminating ability and did not allow the determination of a clinically useful estimate of the probability of uterine rupture for an individual patient. CONCLUSION Factors that were available before or at admission for delivery cannot be used to predict accurately the relatively small proportion of women at term who will experience a uterine rupture during an attempted vaginal birth after cesarean delivery.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA.
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Carroll MA, Vidaeff AC, Mele L, Wapner RJ, Mercer B, Peaceman AM, Sorokin Y, Dudley DJ, Spong CY, Leveno KJ, Harper M, Caritis SN, Miodovnik M, Thorp JM, Moawad A, O'Sullivan MJ, Carpenter MW, Rouse DJ, Sibai B. Bone metabolism in pregnant women exposed to single compared with multiple courses of corticosteroids. Obstet Gynecol 2008; 111:1352-8. [PMID: 18515519 PMCID: PMC2810116 DOI: 10.1097/aog.0b013e318173573b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare markers of maternal bone metabolism between women who received a single compared with multiple courses of antenatal corticosteroids. METHODS This is an analysis of serum samples from a previously reported randomized, placebo-controlled, multicenter trial. Women at risk for preterm delivery after an initial course of corticosteroids were randomly assigned to weekly courses of betamethasone (active) or placebo. Serum levels of carboxy terminal propeptide of type I procollagen (PICP) and cross-linked carboxy terminal telopeptide of type I collagen (ICTP) were measured to assess the rate of bone formation and resorption, respectively, at three time points. The placebo group (n=93) was compared with the active group, receiving four or more courses of betamethasone (n=112). RESULTS There were significant (P<.001) increases in PICP and ICTP between baseline and delivery in both groups. Cross-linked carboxy terminal telopeptide of type I collagen, but not PICP, was lower with corticosteroid exposure immediately before administration of the fourth study course (P<.001). No significant differences in PICP and ICTP were seen between groups at delivery. CONCLUSION Increasing levels of PICP and ICTP with advancing gestation are consistent with physiologic changes in maternal bone metabolism. Multiple courses of corticosteroids for fetal maturation are not associated with persistent or cumulative effects on maternal bone metabolism as measured by PICP and ICTP. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Mary A Carroll
- Department of Obstetrics and Gynecology, University of Texas Houston, Houston, Texas 77030, USA
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Mastrobattista JM, Klebanoff MA, Carey JC, Hauth JC, MacPherson CA, Ernest J, Cotroneo M, Leveno KJ, Wapner R, Varner M, Iams JD, Moawad A, Sibai BM, Miodovnik M, Dombrowski M, O'Sullivan MJ, VanDorsten JP, Langer O. The effect of body mass index on therapeutic response to bacterial vaginosis in pregnancy. Am J Perinatol 2008; 25:233-7. [PMID: 18548397 PMCID: PMC2841559 DOI: 10.1055/s-2008-1066875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Our objective was to determine the effect of body mass index (BMI) on response to bacterial vaginosis (BV) treatment. A secondary analysis was conducted of two multicenter trials of therapy for BV and TRICHOMONAS VAGINALIS. Gravida were screened for BV between 8 and 22 weeks and randomized between 16 and 23 weeks to metronidazole or placebo. Of 1497 gravida with asymptomatic BV and preconceptional BMI, 738 were randomized to metronidazole; BMI was divided into categories: < 25, 25 to 29.9, and > or = 30. Rates of BV persistence at follow-up were compared using the Mantel-Haenszel chi square. Multiple logistic regression was used to evaluate the effect of BMI on BV persistence at follow-up, adjusting for potential confounders. No association was identified between BMI and BV rate at follow-up ( P = 0.21). BMI was associated with maternal age, smoking, marital status, and black race. Compared with women with BMI of < 25, adjusted odds ratio (OR) of BV at follow-up were BMI 25 to 29.9: OR, 0.66, 95% CI 0.43 to 1.02; BMI > or = 30: OR, 0.83, 95% CI 0.54 to 1.26. We concluded that the persistence of BV after treatment was not related to BMI.
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Affiliation(s)
- Joan M. Mastrobattista
- Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, 6431 Fannin Street, Suite 3.274, Houston, Texas 77030, , (713) 500-6412, Fax: (713) 500-7860
| | - Mark A. Klebanoff
- National Institute of Child Health and Human Development, Division of Epidemiology, Statistics & Prevention Research (DESPR), 6100 Executive Boulevard, Room 7B05F, MSC 7510, Bethesda, MD 20892-7510, , (301) 496-5267, Fax: (301) 496-3790
| | - J. Christopher Carey
- Denver Health and Professor, University of Colorado School of Medicine, 777 Bannock St. MC 0660, Denver, CO, 80204, , (303) 602-9715, Fax: (303) 602-9734
| | - John C. Hauth
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham, 618 South 20th Street, Birmingham, AL 35233-7333, , (205) 934-9414, Fax: (205) 975-5723
| | - Cora A. MacPherson
- Department of Epidemiology and Biostatistics, The George Washington University Biostatistics Center, 6110 Executive Boulevard, Suite 750, Rockville, MD, 20852, , (301) 881-9260, Fax: (301) 816-0385
| | - J.M Ernest
- Department of Obstetrics and Gynecology, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, , (336) 716-1025, Fax: (336) 716-6937
| | - Margaret Cotroneo
- Magee Women's Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, 300 Halket Street, Pittsburgh, PA 15213, , (412) 641-4055, Fax: (412) 641-5518
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032, , (214) 648-2316, Fax: (214) 648-4763
| | - Ronald Wapner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia Medical University, 16 East 60th Street, Room 480, New York, NY 10021, , (212) 305-6293, Fax: (212) 305-4380
| | - Michael Varner
- University of Utah Health Sciences Center Department of Obstetrics and Gynecology, 30 North 1900 East, Suite 2B200, Salt Lake City, UT 84132, , (801) 585-5156, Fax: (801) 585-2594
| | - Jay D. Iams
- Ohio State University, Department of Obstetrics and Gynecology, 563 Means Hall, 1654 Upham Drive, Columbus, OH 43210-1228, , (614) 293-8736, Fax: (614) 293-8993
| | - Atef Moawad
- Department of Obstetrics and Gynecology, University of Chicago Medical Center, 5841 S. Maryland MC 2050, Chicago, IL 60637, , (773) 702-5200, Fax: (773) 702-5160
| | - Baha M. Sibai
- University of Cincinnati, Department of Obstetrics and Gynecology, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, , (513) 558-8448, Fax: (513) 558-6138
| | - Menachem Miodovnik
- Department of Obstetrics and Gynecology, Washington Hospital Center, 110 Irving Street, NW, Room 5B-63, Washington, DC 20010, , (202) 877-9663, Fax: (202) 877-5435
| | - Mitchell Dombrowski
- Department of Obstetrics and Gynecology, St. John Hospital, 22151 Moross, Detroit, MI, 48236, , (313) 343-7798, Fax: (313) 343-4932
| | - Mary J. O'Sullivan
- University of Miami, Department of Obstetrics and Gynecology, Division of Research, R 136, Miami, FL, 33123, , (305) 243-7364
| | - J. Peter VanDorsten
- Medical University of South Carolina, Department of Obstetrics and Gynecology, 96 Jonathan Lucas Street, Suite 634, Charleston, SC 29425, , (843) 792-1668, Fax: 843-792-0533
| | - Oded Langer
- Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, Suite 10C-01, New York, NY 10019, , (212) 523-5750, Fax: (212) 523-8066
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Abstract
OBJECTIVE To investigate the relationship between cervical length (CL) at 37 to 40 weeks and delivery within 7 days and delivery by 41 weeks. STUDY DESIGN We performed transvaginal ultrasound to measure CL in women with singleton gestations at 37 to 40 weeks. We then used a receiver operating characteristic curve (ROC) to assess the relationship between CL and delivery within 7 days and delivery by 41 weeks. RESULT For the 120 women included in the analysis, the mean CL (+/-s.d.) was 25.3+/-9.8 mm. The logistic regression model to predict each of the outcomes includes gestational age at ultrasound (GA-US) and CL. Neither birthweight, nor parity seems to affect the probability of delivery within 7 days. The ROC curve was used to assess the probability of spontaneous labor within 7 days at each CL measurement. The likelihood ratio of delivery within 7 days when CL is < or = 10 mm is 12. CONCLUSION CL measurement at 37-40 weeks is an independent predictor of delivery within 7 days and delivery by 41 weeks regardless of GA-US. This information can be utilized when counseling patients regarding the management of term pregnancies.
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Affiliation(s)
- L L Tolaymat
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA.
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44
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Spong CY, Landon MB, Gilbert S, Rouse DJ, Leveno KJ, Varner MW, Moawad AH, Simhan HN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Risk of Uterine Rupture and Adverse Perinatal Outcome at Term After Cesarean Delivery. Obstet Gynecol 2007; 110:801-7. [PMID: 17906012 DOI: 10.1097/01.aog.0000284622.71222.b2] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Current information on the risk of uterine rupture after cesarean delivery has generally compared the risk after trial of labor to that occurring with an elective cesarean delivery without labor. Because antepartum counseling cannot account for whether a woman will develop an indication requiring a repeat cesarean delivery or whether labor will occur before scheduled cesarean delivery, the purpose of this analysis was to provide clinically useful information regarding the risks of uterine rupture and adverse perinatal outcome for women at term with a history of prior cesarean delivery. METHODS Women with a term singleton gestation and prior cesarean delivery were studied over 4 years at 19 centers. For this analysis, outcomes from five groups were studied: trial of labor, elective repeat with no labor, elective repeat with labor (women presenting in early labor who subsequently underwent cesarean delivery), indicated repeat with labor, and indicated repeat without labor. All cases of uterine rupture were reviewed centrally to assure accuracy of diagnosis. RESULTS A total of 39,117 women were studied. In term pregnant women with a prior cesarean delivery, the overall risk for uterine rupture was 0.32% (125 of 39,117), and the overall risk for serious adverse perinatal outcome (stillbirth, hypoxic ischemic encephalopathy, neonatal death) was 106 of 39,049 (0.27%). The uterine rupture risk for indicated repeat cesarean delivery (labor or without labor) was 7 of 6,080 (0.12%); the risk for elective (no indication) repeat cesarean delivery (labor or without labor) was 4 of 17,714 (0.02%). Indicated repeat cesarean delivery increased the risk of uterine rupture by a factor of 5 (odds ratio 5.1, 95% confidence interval 1.49-17.44). In the absence of an indication, the presence of labor also increased the risk of uterine rupture (4 of 2,721 [0.15%] compared with 0 of 14,993, P<.01). The highest rate of uterine rupture occurred in women undergoing trial of labor (0.74%, 114 of 15,323). CONCLUSION At term, the risk of uterine rupture and adverse perinatal outcome for women with a singleton and prior cesarean delivery is low regardless of mode of delivery, occurring in 3 per 1,000 women. Maternal complications occurred in 3-8% of women within the five delivery groups.
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Affiliation(s)
- Catherine Y Spong
- National Institute of Child Health and Human Development, Bethesda, Maryland, USA.
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45
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Louis J, Landon MB, Gersnoviez RJ, Leveno KJ, Spong CY, Rouse DJ, Moawad AH, Varner MW, Caritis SN, Harper M, Wapner RJ, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Perioperative morbidity and mortality among human immunodeficiency virus infected women undergoing cesarean delivery. Obstet Gynecol 2007; 110:385-90. [PMID: 17666615 DOI: 10.1097/01.aog.0000275263.81272.fc] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether human immunodeficiency virus (HIV)-infected women have a higher rate of postcesarean morbidity and mortality compared with women without HIV infection. METHODS A secondary analysis was performed of women with singleton gestations undergoing cesarean delivery with known HIV status. Data were collected as part of a prospective 4-year (1999-2002) observational study and analyzed using logistic regression. Women were surveyed for a large number of intraoperative complications, common perioperative morbidities, and uncommon maternal complications. RESULTS There were 378 HIV-infected and 54,281 uninfected women who met criteria. Patients infected with HIV were more likely to have postpartum endometritis (11.6% compared with 5.8%, P<.001), require a postpartum blood transfusion (4.0% compared with 2.0%, P=.02), develop maternal sepsis (1.1% compared with 0.2%, P<.001), be treated for pneumonia (1.3% compared with 0.3%, P=.001), and to have a maternal death (0.8% compared with 0.1%, P<.001). After controlling for potential confounders, patients with HIV infection were more likely to have one or more postpartum morbidities (odds ratio 1.6, 95% confidence interval 1.2-2.2). CONCLUSION Women with HIV infection undergoing cesarean delivery are at increased risk for perioperative morbidity and maternal mortality. LEVEL OF EVIDENCE II.
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46
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O'Sullivan MJ, Li T, Freedman G, Morrow M. The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery. Ann Surg Oncol 2007; 14:3133-40. [PMID: 17653798 DOI: 10.1245/s10434-007-9523-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 06/19/2007] [Accepted: 06/20/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions. METHODS 2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months. RESULTS The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%, and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p < 0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision. CONCLUSIONS Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/etiology
- Prospective Studies
- Reoperation
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Affiliation(s)
- M J O'Sullivan
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111-2497, USA
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47
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Abstract
Prophylactic antimicrobial therapy is defined as the administration of an antimicrobial agent prior to contamination of previously sterile tissues or fluids, in an attempt to reduce the microbial burden of intraoperative contamination. Prophylactic antimicrobial therapy should cover the anticipated floral contamination, with therapeutic levels from incision to closure. There is level I evidence to support the use of prophylaxis in clean-contaminated head and neck procedures and tonsillectomy, while level II evidence fails to support the use of prophylaxis in clean head and neck procedures. The aim of this study was to evaluate the use, timing and appropriateness of antimicrobial prophylaxis perioperatively, in otorhinolaryngological/head and neck procedures. A total of 34/51 (66%) patients were administered antimicrobial agents prophylactically. Six of 19 patients (42%) who ought to have received prophylaxis did not, while six of 13 (46%) of those who did not require it received it. Administration was unsuitably timed in 14 of 34 (41%) operations. This study demonstrates unnecessary administration of antimicrobial agents perioperatively, subclinical intraoperative antimicrobial levels for prophylaxis and inconsistent documentation regarding prophylaxis in otorhinolaryngological/head and neck procedures in a general ENT unit.
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Affiliation(s)
- B G Fennessy
- Department of Otorhinolaryngology, The Royal Victoria Eye and Ear Hospital, Dublin, Ireland.
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48
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Alexander JM, Leveno KJ, Rouse DJ, Landon MB, Gilbert S, Spong CY, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, Sibai BM, Langer O, Gabbe SG. Comparison of Maternal and Infant Outcomes From Primary Cesarean Delivery During the Second Compared With First Stage of Labor. Obstet Gynecol 2007; 109:917-21. [PMID: 17400854 DOI: 10.1097/01.aog.0000257121.56126.fe] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare maternal and neonatal outcomes when primary cesarean delivery is performed in the second stage of labor compared with the first stage. METHODS Between January 1, 1999, and December 31, 2000, a prospective observational study of primary cesarean deliveries was conducted at 13 university centers comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The primary outcomes of interest included a maternal composite (composed of at least one of the following: endometritis, intraoperative surgical complication, blood transfusion, or wound complication) and neonatal composite (which included at least one of the following: Apgar score of 3 or less at 5 minutes, neonatal death, neonatal intensive care unit admission, seizure, delivery room intubation in the absence of meconium, or fetal injury). RESULTS A total of 11,981 cesarean deliveries were available for analysis: 9,265 were performed in the first stage and 2,716 in the second stage. Cesarean deliveries performed in the second stage were associated with longer operative times, epidural analgesia, chorioamnionitis, and higher birth weight (all P<.001). The maternal composite index was slightly increased in women undergoing cesarean delivery in the second stage of labor, primarily due to uterine atony, uterine incision extension, and incidental cystotomy. This difference was significant after multivariable analysis (odds ratio 1.21, 95% confidence interval 1.07-1.37). After multivariable analysis, the neonatal composite did not differ significantly between groups (odds ratio 0.96, 95% confidence interval 0.84-1.08). CONCLUSION Cesarean delivery in the second stage of labor is associated with slightly increased maternal but not neonatal composite morbidity. LEVEL OF EVIDENCE II.
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Affiliation(s)
- James M Alexander
- Department of Obstetrics and Gynecology at the University of Texas Southwestern Medical Center, Dallas, Texas 75235-9032, USA.
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49
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Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM. Development of a Nomogram for Prediction of Vaginal Birth After Cesarean Delivery. Obstet Gynecol 2007; 109:806-12. [PMID: 17400840 DOI: 10.1097/01.aog.0000259312.36053.02] [Citation(s) in RCA: 298] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To develop a model based on factors available at the first prenatal visit that predicts chance of successful vaginal birth after cesarean delivery (VBAC) for individual patients who undergo a trial of labor. METHODS All women with one prior low transverse cesarean who underwent a trial of labor at term with a vertex singleton gestation were identified from a concurrently collected database of deliveries at 19 academic centers during a 4-year period. Using factors identifiable at the first prenatal visit, we analyzed different classification techniques in an effort to develop a meaningful prediction model for VBAC success. After development and cross-validation, this model was represented by a graphic nomogram. RESULTS Seven-thousand six hundred sixty women were available for analysis. The prediction model is based on a multivariable logistic regression, including the variables of maternal age, body mass index, ethnicity, prior vaginal delivery, the occurrence of a VBAC, and a potentially recurrent indication for the cesarean delivery. After analyzing the model with cross-validation techniques, it was found to be both accurate and discriminating. CONCLUSION A predictive nomogram, which incorporates six variables easily ascertainable at the first prenatal visit, has been developed that allows the determination of a patient-specific chance for successful VBAC for those women who undertake trial of labor. LEVEL OF EVIDENCE II.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology at Northwestern University, Chicago, Illinois 60611, USA.
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Moran DE, Smith MJ, O'Sullivan MJ, Bannon H, Crotty TB, Collins CD, Skehan SJ, O'Higgins N, McDermott EW, Evoy D, Hill ADK. Sentinel lymph node biopsy in elderly irish patients with malignant melanoma. Ir Med J 2007; 100:422-4. [PMID: 17566474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In patients with malignant melanoma, Breslow depth increases with age. However, studies suggest that the frequency of sentinel lymph node metastases in malignant melanoma decreases with age. We investigated whether this applied to the cohort of patients undergoing sentinel lymph node biopsy (SLNB) in our institution. In a prospectively accrued database we identified 149 patients undergoing SLNB from 1997 to 2005. Tumour thickness as measured by Breslow depth was assessed in stratified age groups. We assessed the relationship between SLNB positivity and age using the Chi-square for trend. We directly examined the relationship between SLNB positivity in patients aged less than 65 and aged 65 years of age and over. Disease-free and overall survival in patients aged less than 65 and aged 65 years of age and over were also assessed. Comparing the age groups, there was no significant difference identified in Breslow depth (<65 years, median Breslow > or = 1.2 mm (range 0.2-9.7); > or =65 years, median Breslow > or = 1.4 mm (range 0.12-8.5); p > or = 0.06, Mann-Whitney U). Chi-square for trend identified no significant relationship between SLNB positivity and age. We found n=120 patients <65 had SLNB, of which 26 (21.7%) were positive. In patients =65, n=29 had SLNB of which 3 (10.3%) were positive. These differences were not statistically significant (Fisher's exact test, p > or = 0.2). There was no difference in disease-free or overall survival between patients aged <65 or > or =65 who had SLNB (median follow-up 37.5 months (range 5-70); disease-free survival, p > 0.08; overall survival, p > or = 0.3, Logrank test). We did not find that elderly patients with malignant melanoma had a demonstrable difference in tumour thickness when compared to younger patients. In those patients who underwent SLNB there was no significant difference in node positivity between the age groups. Disease-free and overall survival were not significantly different between the age groups. Further study and longer follow-up will help establish the relationship between age and SLNB positivity.
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Affiliation(s)
- D E Moran
- Department of Surgery, Saint Vincent's University Hospital, Elm Park, Dublin
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