Barriers to fertility preservation access in transgender and gender diverse adolescents: a narrative review

Fertility preservation (FP) involves the cryopreservation of gametes, embryos, and/or gonadal tissue oocytes, for future use in family building. FP as part of a comprehensive approach to care of transgender and gender diverse (TGD) individuals is an understudied topic. Current evidence indicates that gender affirming therapies may increase the risk for infertility. As a result, TGD individuals, including adolescents, should receive counseling regarding FP prior to beginning gender affirming treatment. Many barriers exist to TGD adolescents receiving FP counseling and undergoing FP if desired. The objective of this narrative review is to summarize the literature regarding the desire for FP in TGD adolescents, the barriers to TGD adolescents in accessing of FP, and to discuss potential interventions for alleviation of such barriers. A literature search using the following Medical Subject Headings search terms: 'transgender persons' and 'fertility preservation' and 'adolescents' was conducted via searching PubMed. Additional articles were located via reference review. Included articles consist of qualitative and quantitative research and society guidelines. Articles from inception to 1st July 2023 were included. The results of the literature search have been summarized into the format of a narrative review. Key barriers to FP for TGD adolescents include inconsistencies in form and timing of counseling, potential worsening of gender dysphoria with FP treatment, high cost of treatment, limited research on FP outcomes, and legal barriers. Intersectionality between gender identity and other forms of minority status can compound these barriers to FP and healthcare in general. Barriers to TGD adolescents accessing FP are significant. Increased research is needed upon methods to mitigate these barriers. Solutions include increasing uniformity and timing of FP counseling by varying health care providers, advocacy efforts to mitigate legal and financial barriers, increased research efforts in FP outcomes, and increased cultural competency in clinics offering FP care to TGD adolescents.

LBMON236 Investigating The Effect Of Social Vulnerability Index On Fibroid Recurrence And Metabolic Dysfunction

Fibroids and metabolic dysfunction disproportionately affect women of color. We have previously shown that recurrent fibroids and metabolic dysfunction lead to increased healthcare utilization. The impact of socioeconomic factors on access to care for these women is poorly understood. Our objective was to evaluate the social vulnerability indices of women with fibroids with and without metabolic dysfunction, and determine the association of social vulnerability with fibroid recurrence. We conducted a retrospective cohort study of 918 geocoded patients who underwent myomectomy at a tertiary health care system. The primary exposure was the Social Vulnerability Index (SVI), a measure of socioeconomic disadvantage developed by the CDC with four thematic subgroups (socioeconomic status, household composition, Race/Ethnicity/Language, and Housing/Transportation). The primary outcome was clinically significant fibroid recurrence after initial myomectomy, defined as symptomatic fibroids requiring re-imaging or surgery. SVI was analyzed as an overall score and by quartiles. Models were adjusted for age, race, and insurance status, with metabolic dysfunction analyzed separately as a covariate. Patients were classified as having metabolic dysfunction (MD) if they met any 2 of 5 WHO or NCEP ATP III criteria for metabolic syndrome with BMI as proxy for waist circumference. Appropriate parametric and non-parametric tests and logistic regression were used to determine the association of SVI with fibroid recurrence. The mean SVI score for the cohort was 0.58 (SD 0.31). Mean SVI scores for patients with and without clinically significant fibroid recurrence were similar at 0.56 (SD 0.30) and 0.57 (SD 0.30), respectively. There remained no association between mean SVI score and odds of fibroid recurrence in adjusted models (OR 0.35, CI 0.10-1.24, p 0.11). Notably, there was a decreased rate of radiologic fibroid recurrence in the highest quartile of SVI (p=0. 011) and an increased rate in the third quartile (p=0. 015). When isolating the individual themes of the SVI index, there was a significant decrease in surgical and radiologic fibroid recurrence in individuals with the highest quartile of minority and language vulnerability (p=0. 03). The odds of metabolic dysfunction increased by 2.9 with each unit increase in SVI (OR 2.85, CI 1.34-6. 07, p 0. 006) after adjusting for age, race, and insurance status. We report that while patients with a higher SVI have increased risk of metabolic dysfunction, this does not translate to higher rates of clinical significant fibroid recurrence. Higher SVI is associated with lower resourced settings and reduced access to care and can therefore be used as a starting point for public health policy. SVI should be considered when studying fibroids, and may illuminate potential barriers in access to care for fibroid recurrence in patients with a history of myomectomy.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Elevated hCG Concentration in a Patient after an Unsuccessful in vitro Fertilization

A patient had a positive serum human chorionic gonadotropin (hCG) 22 days after a failed in vitro fertilization (IVF). The result was confirmed by repeating the test using quantitative and qualitative assays after 48 hours, but the quantitative result did not double compared to the previous concentration. Heterophilic antibody interference was ruled out. The above results indicated true-positive hCG, but inconsistent with normal pregnancy. Medical history excluded hCG produced by pituitary gland, malignancy and exogenous hCG use. Ectopic pregnancy (EP) was suspected and methotrexate was initiated. Ultrasound showed periadnexal fluid suggesting separation phenomenon on the right adnexal EP and hCG was decreased one weeks after the treatment. Two weeks later, hCG became negative. The above data suggest that the elevated hCG was most likely due to EP following IVF.

Evaluation of Stillbirth Among Pregnant People With Sickle Cell Trait

IMPORTANCE

Relative to what is known about pregnancy complications and sickle cell disease (SCD), little is known about the risk of pregnancy complications among those with sickle cell trait (SCT). There is a lack of clinical research among sickle cell carriers largely due to low sample sizes and disparities in research funding.

OBJECTIVE

To evaluate whether there is an association between SCT and a stillbirth outcome.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included data on deliveries occurring between January 1, 2010, and August 15, 2017, at 4 quaternary academic medical centers within the Penn Medicine health system in Pennsylvania. The population included a total of 2482 deliveries from 1904 patients with SCT but not SCD, and 215 deliveries from 164 patients with SCD. Data were analyzed from May 3, 2019, to September 16, 2021.

EXPOSURES

The primary exposure of interest was SCT, identified using clinical diagnosis codes recorded in the electronic health record.

MAIN OUTCOMES AND MEASURES

A multivariate logistic regression model was constructed to assess the risk of stillbirth using the following risk factors: SCD, numbers of pain crises and blood transfusions before delivery, delivery episode (as a proxy for parity), prior cesarean delivery, multiple gestation, patient age, marital status, race and ethnicity, ABO blood type, Rhesus (Rh) factor, and year of delivery.

RESULTS

This cohort study included 50 560 patients (63 334 deliveries), most of whom were aged 25 to 34 years (29 387 of 50 560 [58.1%]; mean [SD] age, 29.5 [6.1] years), were single at the time of delivery (28 186 [55.8%]), were Black or African American (23 777 [47.0%]), had ABO blood type O (22 879 [45.2%]), and were Rhesus factor positive (44 000 [87.0%]). From this general population, 2068 patients (4.1%) with a sickle cell gene variation were identified: 1904 patients (92.1%) with SCT (2482 deliveries) and 164 patients (7.9%) with SCD (215 deliveries). In the fully adjusted model, SCT was associated with an increased risk of stillbirth (adjusted odds ratio [aOR], 8.94; 95% CI, 1.05-75.79; P = .045) while adjusting for the risk factors of SCD (aOR, 26.40; 95% CI, 2.48-280.90; P = .007) and multiple gestation (aOR, 4.68; 95% CI, 3.48-6.29; P < .001).

CONCLUSIONS AND RELEVANCE

The results of this large, retrospective cohort study indicate an increased risk of stillbirth among pregnant people with SCT. These findings underscore the need for additional risk assessment during pregnancy for sickle cell carriers.

Trainee Sex and Accreditation Council for Graduate Medical Education Milestone Assessments During General Surgery Residency

Importance

In evaluating the effectiveness of general surgery (GS) training, an unbiased assessment of the progression of residents with attention to individual learner factors is imperative.

Objective

To evaluate the role of trainee sex in milestone achievement over the course of GS residency using national data from the Accreditation Council for Graduate Medical Education (ACGME).

Design, Setting, and Participants

This cross-sectional study evaluated female and male GS residents enrolled in ACGME-accredited programs in the US from 2014 to 2018 with reported variation in milestones performance across years in training and representation. Data were analyzed from November 2019 to June 2021.

Main Outcomes and Measures

Mean reported milestone score at initial and final assessment, and predicted time-to-attainment of equivalent performance by sex.

Results

Among 4476 GS residents from 250 programs who had milestone assessments at any point in their clinical training, 1735 were female (38.8%). Initially, female and male residents received similar mean (SD) milestone scores (1.95 [0.50] vs 1.94 [0.50]; P = .69). At the final assessment, female trainees received overall lower mean milestone scores than male trainees (4.25 vs 4.31; P < .001). Significantly lower mean milestone scores were reported for female residents at the final assessment for several subcompetencies in both univariate and multivariate analyses, with only medical knowledge 1 (pathophysiology, diagnosis, and initial management) common to both. Multilevel mixed-effects linear modeling demonstrated that female trainees had significantly lower rates of monthly milestone attainment in the subcompetency of medical knowledge 1, which was associated with a significant difference in training time of approximately 1.8 months.

Conclusions and Relevance

Both female and male GS trainees achieved the competency scores necessary to transition to independence after residency as measured by the milestones assessment system. Initially, there were no sex differences in milestone score. By graduation, there were differences in the measured assessment of female and male trainees across several subcompetencies. Careful monitoring for sex bias in the evaluation of trainees and scrutiny of the training process is needed to ensure that surgical residency programs support the educational needs of both female and male trainees.

Knowledge of PCOS in physicians-in-training: identifying gaps and educational opportunities

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. A recent study found that many obstetrics and gynecology (ObGyn) practicing physicians are unaware of the Rotterdam criteria recommended for diagnosis. Our objective was to identify gaps in trainee knowledge of PCOS diagnostic criteria and management. An online survey was sent out to US ObGyn physicians-in-training in 2018. The primary outcomes were identification of at least one component of each Rotterdam criteria (Rot-3): (1) oligomenorrhea/amenorrhea, (2) clinical or biochemical hyperandrogenism, and (3) ovarian volume or antral follicle count, and identification of all five components (Rot-5). Secondary outcomes were identification of comorbidities and management of PCOS. Multivariable logistic regression was used controlling for gender, seniority (PGY) status, program type, completion of an REI rotation, and number of PCOS patients seen. 85.4% of 347 trainees completing the survey reported using Rotterdam criteria to diagnose PCOS. However, only 55% identified Rot-3 and less than 10% identified Rot-5. Seniority (PGY4 OR 2.2; 95% CI: 1.2-4.1; p = .01) and completion of REI rotation (OR 1.8 95% CI: 1.2, 1.8; p = .006) were associated with identifying Rot-3. Similar findings were noted with identifying Rot-5. Our study identified significant gaps in knowledge regarding PCOS, suggesting an urgent need for improving strategies for trainee education to increase patient satisfaction and provide comprehensive care.

Predictors of Steroid Hormone Concentrations in Early Pregnancy: Results from a Multi-Center Cohort

Objectives To identify factors predicting maternal sex steroid hormone concentrations in early pregnancy. Methods The Infant Development and the Environment Study recruited healthy pregnant women from academic medical centers in four US cities. Gold standard liquid chromatography-tandem mass spectrometry was used to measure maternal sex steroids concentrations (total testosterone [TT], free testosterone [FT], estrone [E1], estradiol [E2], and estriol [E3] concentrations) in serum samples from 548 women carrying singletons (median = 11.7 weeks gestation). Women completed questionnaires on demographic and lifestyle characteristics. Results In multivariable linear regression analyses, hormone concentrations varied in relation to maternal age, body mass index (BMI), race, and parity. Older mothers had significantly lower levels of most hormones; for every year increase in maternal age, there was a 1-2% decrease in E1, E2, TT, and FT. By contrast, each unit increase in maternal BMI was associated 1-2% lower estrogen (E1, E2, E3) levels, but 1-2% higher androgen (TT, FT) concentrations. Hormone concentrations were 4-18% lower among parous women, and for each year elapsed since last birth, TT and FT were 1-2% higher (no difference in estrogens). Androgen concentrations were 18-30% higher among Black women compared to women of other races. Fetal sex, maternal stress, and lifestyle factors (including alcohol and tobacco use) were not related to maternal steroid concentrations. Conclusions for Practice Maternal demographic factors predict sex steroid hormone concentrations during pregnancy, which is important given increasing evidence that the prenatal endocrine environment shapes future risk of chronic disease for both mother and offspring.

Maternal urinary phthalate metabolites in relation to gestational diabetes and glucose intolerance during pregnancy

BACKGROUND

Phthalates are common plasticizer chemicals that have been linked to glucose intolerance in the general population, but there is only limited research on their association with gestational diabetes (GDM).

OBJECTIVE

We evaluated the association between 11 urinary phthalate metabolites and GDM, impaired glucose tolerance (IGT), and continuous blood glucose concentration during pregnancy in The Infant Development and Environment Study (TIDES). Based on prior study results, our primary analyses focused on monoethyl phthalate (MEP) in relation to our outcomes of interest.

STUDY DESIGN

We used multi-variable logistic regression to examine the odds of GDM and IGT in relation to an interquartile-range (IQR) increase in natural log (ln)-transformed, specific gravity (SG)-adjusted first trimester (T1) and average of T1 and third trimester (T3) ("T1T3avg") phthalate metabolite concentrations. We fit linear regression models to examine the percent change in blood glucose per IQR increase in ln-transformed, SG-adjusted T1 and T1T3avg phthalates. In sensitivity analyses, we examined interactions between exposure and race. We adjusted for maternal age, maternal body mass index, study center, race/ethnicity, parity, and gestational age at glucose testing.

RESULTS

In our sample of 705 pregnant women, we observed 60 cases of GDM, 90 cases of IGT, and an average GLT blood glucose of 113.6 ± 27.7 mg/dL. In our primary analysis, T1T3avg MEP was positively associated with GDM ([OR (95% CI) per IQR increase] T1T3avg MEP: 1.61 (1.10, 2.36)). In secondary analyses, most other phthalates were not found to be related to study outcomes, though some associations were noted. Sensitivity analyses indicated possible strong race-specific associations in Asians, though these results are based on a small sample size (n = 35).

CONCLUSION

In alignment with our a priori selection, we documented an association between T1T3avg MEP and GDM. Additional phthalate metabolites were also found to be linked to glucose intolerance, with possible stronger associations in certain racial/ethnic subgroups. Given the prevalence of phthalate exposures and the growing evidence of associations with metabolic outcomes, future studies should continue to examine this question in diverse cohorts of pregnant women, particularly in those who may be at higher risk for GDM and IGT.

Early Prenatal Phthalate Exposure, Sex Steroid Hormones, and Birth Outcomes

CONTEXT

Adequate sex steroid hormone concentrations are essential for normal fetal genital development in early pregnancy. Our previous study demonstrated an inverse relationship between third-trimester di-2-ethyl hexyl phthalate exposure and total testosterone (TT) concentrations. Here, we examine early-pregnancy phthalates, sex steroid hormone concentrations, and newborn reproductive outcomes.

DESIGN

We examined associations between urinary phthalate metabolite concentrations in early pregnancy and serum free testosterone (FT), TT, estrone (E1), and estradiol (E2) in 591 woman/infant dyads in The Infant Development and Environment Study; we also examined relationships between hormones and newborn genital outcomes using multiple regression models with covariate adjustment.

RESULTS

E1 and E2 concentrations were 15% to 30% higher in relation to 1-unit increases in log monoisobutyl phthalate (MiBP), mono-2-ethyl hexyl phthalate, and mono-2-ethyl-5-oxy-hexyl phthalate concentrations, and E2 was 15% higher in relation to increased log monobenzyl phthalate (MBzP). FT concentrations were 12% lower in relation to 1-unit increases in log mono(carboxynonyl) phthalate (MCNP) and mono-2-ethyl-5-carboxypentyl phthalate concentrations. Higher maternal FT was associated with a 25% lower prevalence of having a male genital abnormality at birth.

CONCLUSIONS

The positive relationships between MiBP, MBzP, and DEHP metabolites and E1/E2 are unique and suggest a positive estrogenic effect in early pregnancy. The inverse relationship between MCNP and DEHP metabolites and serum FT supports previous work examining phthalate/testosterone relationships later in pregnancy. Higher FT in relation to a 25% lower prevalence of male genital abnormalities confirms the importance of testosterone in early fetal development.

ASRM standard embryo transfer protocol template: a committee opinion

Standardization improves performance and safety. A template for standardizing the embryo transfer procedure is presented here with 12 basic steps supported by published scientific literature and a survey of common practice of SART programs; it can be used by ART practices to model their own standard protocol.

A Molecular Perspective on Procedures and Outcomes with Assisted Reproductive Technologies

The emerging association of assisted reproductive technologies with adverse perinatal outcomes has prompted the in-depth examination of clinical and laboratory protocols and procedures and their possible effects on epigenetic regulatory mechanism(s). The application of various approaches to study epigenetic regulation to problems in reproductive medicine has the potential to identify relative risk indicators for particular conditions, diagnostic biomarkers of disease state, and prognostic indicators of outcome. Moreover, when applied genome-wide, these techniques are likely to find novel pathways of disease pathogenesis and identify new targets for intervention. The analysis of DNA methylation, histone modifications, transcription factors, enhancer binding and other chromatin proteins, DNase-hypersensitivity and, micro- and other noncoding RNAs all provide overlapping and often complementary snapshots of chromatin structure and resultant "gene activity." In terms of clinical application, the predictive power and utility of epigenetic information will depend on the power of individual techniques to discriminate normal levels of interindividual variation from variation linked to a disease state. At present, quantitative analysis of DNA methylation at multiple loci seems likely to hold the greatest promise for achieving the level of precision, reproducibility, and throughput demanded in a clinical setting.

Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulation-intrauterine insemination

OBJECTIVE

To identify baseline characteristics of couples that are likely to predict conception, clinical pregnancy, and live birth after up to four cycles of ovarian stimulation with IUI in couples with unexplained infertility.

DESIGN

Secondary analyses of data from a prospective, randomized, multicenter clinical trial investigating pregnancy, live birth, and multiple pregnancy rates after ovarian stimulation-IUI with clomiphene citrate, letrozole, or gonadotropins.

SETTING

Outpatient clinical units.

PATIENT(S)

Nine-hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial.

INTERVENTION(S)

As part of the clinical trial, treatment was randomized equally to one of three arms and continued for up to four cycles or until pregnancy was achieved.

MAIN OUTCOME MEASURE(S)

Conception, clinical pregnancy, and live-birth rates.

RESULT(S)

In a multivariable logistic regression analysis, after adjustment for other covariates, age, waist circumference, income level, duration of infertility, and a history of prior pregnancy loss were significantly associated with at least one pregnancy outcome. Other baseline demographic and lifestyle characteristics including smoking, alcohol use, and serum levels of antimüllerian hormone were not significantly associated with pregnancy outcomes.

CONCLUSION(S)

While age and duration of infertility were significant predictors of all pregnancy outcomes, many other baseline characteristics were not. The identification of level of income as a significant predictor of outcomes independent of race and education may reflect differences in the underlying etiologies of unexplained infertility or could reveal disparities in access to fertility and/or obstetrical care.

CLINICAL TRIAL REGISTRATION

NCT01044862.

Decreased cholesterol efflux capacity and atherogenic lipid profile in young women with PCOS

CONTEXT

Women with polycystic ovary syndrome (PCOS) have a high prevalence of cardiovascular disease (CVD) risk factors including dyslipidemia. Lipoproteins are heterogeneous, and measurement of serum lipids provides only the size of the pool and does not predict their function or composition. Recently, high-density lipoprotein cholesterol (HDL-C) function, as determined by cholesterol efflux capacity from macrophages, has been shown to be an independent predictor of subclinical CVD.

OBJECTIVE

The aim of the study was to comprehensively evaluate lipoprotein profile including lipid particle size and number and cholesterol efflux capacity in PCOS to better define CVD risk.

DESIGN AND SETTING

A case control study was performed at an academic PCOS center.

PATIENTS

Women with PCOS (n = 124) and geographically matched controls (n = 67) were included in the study.

MAIN OUTCOME MEASURES

The primary outcome was to measure HDL-C efflux capacity by an ex vivo system involving the incubation of macrophages with apolipoprotein (Apo) B-depleted serum from subjects, and the secondary outcome was to measure lipid particle size and number using nuclear magnetic resonance spectroscopy.

RESULTS

Women with PCOS had significantly higher body mass index and blood pressure but similar HDL-C and low-density lipoprotein cholesterol levels compared to controls. The mean ApoA1 levels were lower, and the ApoB/ApoA1 ratio was higher in PCOS subjects compared to controls (P < .01). There were no differences in ApoB levels. Women with PCOS had an 7% decrease in normalized cholesterol efflux capacity compared to controls (P < .003). Cholesterol efflux capacity in PCOS correlated with body mass index, ApoA1, HDL-C, and the presence of metabolic syndrome. In a multivariable regression model, PCOS was significantly associated with diminished cholesterol efflux. PCOS was also associated with an atherogenic profile including an increase in large very low-density lipoprotein particles, very low-density lipoprotein (VLDL) size, and small low-density lipoprotein cholesterol particles (P < .01).

CONCLUSIONS

Our novel findings of decreased cholesterol efflux and an atherogenic lipid particle number and size pattern in women with PCOS, independent of obesity, further substantiate the increased risk of CVD in this population.

Phthalate exposure and reproductive hormone concentrations in pregnancy

Some phthalate chemicals can affect hormone physiology in utero, resulting in adverse reproductive health outcomes in animal models. It is unknown whether these exposures are related to circulating maternal hormone concentrations during pregnancy. We used multivariate linear regression to estimate associations between phthalate metabolite concentrations and concurrent serum-free and total testosterone and estradiol (E2) levels in 180 pregnant women in the Study for Future Families. We also examined associations between prenatal serum hormone concentrations and anogenital outcome in infants. All analyses were adjusted for appropriate confounding variables. Total testosterone, free testosterone, and E2 concentrations ranged from 8 to 406 ng/dl, 0.03 to 1.2 ng/dl, and 529 to 40 600 pg/ml respectively. We observed an inverse association between log-sum di-2-ethylhexyl phthalate (DEHP) metabolite concentrations and lower log-total testosterone concentrations (-0.15, 95% CI -0.26, -0.04) and log-free testosterone (-0.15, 95% CI -0.27, -0.03). This relationship persisted regardless of fetal sex. Similarly, we observed an inverse association between log monobutyl phthalate (MBP) concentrations and log-total and -free testosterone concentrations in women carrying male fetuses. Monoethyl phthalate (MEP) concentrations were positively associated with log-total and -free testosterone concentrations in women carrying male fetuses (0.09, 95% CI 0.003, 0.17 and 0.10, 95% CI 0.01, 0.19 respectively). Prenatal hormone concentrations were not significantly associated with infant anogenital outcomes. Our preliminary data suggest that DEHP metabolite, MBP, and MEP exposures during pregnancy are associated with prenatal sex steroid hormone concentrations, but sex steroid hormone concentrations were not associated with infant reproductive outcomes.

Correlation of telomere length and telomerase activity with occult ovarian insufficiency

BACKGROUND

Occult ovarian insufficiency is associated with infertility, impaired response to ovarian stimulation, and reduced live birth rates in women treated with assisted reproductive technologies. Although a decline in ovarian follicle number is expected with age, the proximate causes of occult ovarian insufficiency in young women remain poorly understood. Abnormalities in telomere length and telomerase activity in human granulosa cells may serve as molecular markers for this condition.

METHODS

A cross-sectional study was performed. Subjects (37 yr old or less) undergoing in vitro fertilization were classified as cases of occult ovarian insufficiency or controls with mechanical infertility (male or tubal factor). Granulosa cells were acquired at the time of oocyte retrieval to quantify telomere length and telomerase activity.

RESULTS

Fifty-four women were enrolled. Human granulosa cell telomerase activity was demonstrated, and lack of granulosa cell telomerase activity was associated with occult ovarian insufficiency (odds ratio, 11.0; 95% confidence interval, 1.3-495.6; P = 0.02). Telomeres were shorter in women with occult ovarian insufficiency than in controls (relative telomere/single copy gene ratio, 1.88 vs. 3.15; P = 0.039).

CONCLUSIONS

Aberrant telomere homeostasis is associated with occult ovarian insufficiency in young women. This finding is consistent with the presence of telomeric attenuation that has been shown in multiple age-related conditions.

Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study

BACKGROUND

The earliest determinants of obesity may operate during intrauterine life, and gestational weight gain may influence the intrauterine environment in a way that may affect the risk of overweight in the offspring.

OBJECTIVE

The purpose of this study was to examine the association of gestational weight gain with offspring overweight.

DESIGN

This was a retrospective cohort study of 10,226 participants from the Collaborative Perinatal Project (1959-1972). Anthropometric and sociodemographic variables were assessed during gestation, at birth, and at age 7 y. The association between gestational weight gain and offspring overweight at 7 y was examined after adjustment for important confounding factors.

RESULTS

The odds of overweight in offspring at age 7 y increased by 3% for every 1 kg of gestational weight gain (adjusted odds ratio: 1.03; 95% CI: 1.02, 1.05). When gestational weight gain was examined using Institute of Medicine guidelines, the odds of overweight was 48% greater for children of mothers who gained more than the weight gain recommendations than for children of mothers who met the weight gain guidelines (adjusted OR: 1.48; 95% CI: 1.06, 2.06). The association remained significant after additional adjustment for birth weight. The association between gestational weight gain and overweight in the offspring was strongest for women who were underweight before pregnancy (P for interaction < 0.01).

CONCLUSION

Helping pregnant women to meet the recommended weight gain during pregnancy may be an important and novel strategy for preventing pediatric obesity.

Ovarian Tissue Preservation and Future Fertility: Emerging Technologies and Ethical Considerations

Both adult women and prepubertal girls facing cancer treatment may have the option to harvest and cryopreserve ovarian tissue. If they have successful therapy for their disease, the tissue may be autotransplanted back into the woman's body or follicles may be harvested and matured in vitro. These techniques all remain experimental, however, and should be performed only by specialized centers that can provide a multidisciplinary team. The procedures should be done under approval from an Institutional Review Board with proper assurance of informed consent. Although the costs for research could be assessed to patients if no research funds are available, clinical fees should not be charged at this stage in the development of these technologies. Consideration should be given to the protection of minors by ensuring parental informed consent and child assent whenever possible. Disposition of cryopreserved gonadal tissue in the event of the participant's death should be formally designated. A registry should be established to follow the health of participants and their eventual offspring.

Risk factors and clinical features of recurrent ectopic pregnancy: a case control study

OBJECTIVE

To compare signs and symptoms between patients with recurrent and single ectopic pregnancies.

DESIGN

Case-control study.

SETTING

University medical center.

PATIENT(S)

Three hundred six women with single ectopic pregnancies and 61 women with recurrent ectopic pregnancies.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Risk factors, historical factors, and findings at presentation that may predispose to recurrent ectopic pregnancy.

RESULT(S)

The risk of recurrent ectopic pregnancy was increased with a history of surgery, history of live birth, and history of spontaneous miscarriage and not with a history of gonorrhea, chlamydia, pelvic inflammatory disease, Caesarean section, or pregnancy termination. Patients with a recurrent ectopic pregnancy had a nonsignificant trend toward higher initial hCG values. The majority of ultrasounds in both groups were nondiagnostic on presentation. The patients with recurrent ectopic pregnancy were less likely to have bleeding on initial presentation, though both groups had similar complaints of pain.

CONCLUSION(S)

Secondary prevention of ectopic pregnancy is problematic because of the paucity of risk factors that can be modified to diminish the odds of recurrence. Clinicians' ability to both diagnose and counsel patients at risk for recurrent ectopic pregnancy can be optimized by awareness of the clinical features of this condition.

Rheumatology telephone helplines: an activity analysis. South and West of England Rheumatology Consortium

BACKGROUND

Anecdotal evidence suggests that the services offered by rheumatology telephone helplines in the UK vary widely between NHS Trusts because of the lack of national or European guidelines.

OBJECTIVE

To conduct an activity analysis of six NHS Trust rheumatology telephone helplines in the south and west of England.

METHODS

Serial data were collected on the first 100 calls received on or after 1 January 1999 by six rheumatology helplines in the south and west of England. Background information was gathered on the management, availability, setting and purpose of each helpline. Data on the time taken to manage these calls and patient satisfaction were not collected.

RESULTS

Patients with rheumatoid arthritis were the major users and no significant differences were found in the outcome of their calls between centres, but wide variations were revealed in the management of the helplines, the populations they serve and the services they offer.

CONCLUSION

The rheumatology helpline services in six NHS Trusts in the south and west of England were shown to be the same in name only. They lacked uniformity in the delivery of care and accessibility to relevant patient groups. The geographical variation in service delivery may result in patient dissatisfaction and confusion if a number of hospitals are attended over the course of a patient's chronic disease. Further research is required to identify the helpline needs of the broader rheumatology population, patient satisfaction, outcomes and system costs, and to progress towards the development of national and European guidelines.

Clinical and serological associations with anti-RNA polymerase antibodies in systemic sclerosis

There are three classes of RNA polymerase enzyme (RNAPs I, II and III). In systemic sclerosis (SSc), three main groups of anti-RNAP sera have been characterized by radioimmunoprecipitation techniques: anti-RNAP I/III sera, anti-RNAP I/II/III sera, and a group precipitating both RNAP II and topoisomerase I (topo I). Some sera in this third group precipitate the phosphorylated (IIO) form of RNAP II in the absence of the unphosphorylated (IIA) form. Certain other antinuclear antibodies (ANA) have also been detected in anti-RNAP IIO/IIA/topo I and anti-RNAP IIO/topo I sera. In the present study of 155 SSc patients, clinical features of individuals from each of these antibody groups were assessed and compared with those of patients from other autoantibody-defined groups. The anti-RNAP I/II/III antibody specificity was closely associated with the presence of diffuse cutaneous SSc (dc-SSc) (77.8%; cf. remaining group, 12.4%; P < 0.001; relative risk (RR) 6.3). Patients with anti-RNAP I/III antibodies also had an increased incidence of dc-SSc, but this was not significant (42.9%; cf. remainder, 15.7%). Anti-RNAP+ patients had a significantly increased incidence of renal involvement (29.0%, cf. remainder, 11.3%; P < 0.05; RR 2.6), with 40% of anti-RNAP I/II/III patients having renal disease. Meanwhile, the presence of anti-centromere antibodies (ACA) was associated with limited cutaneous SSc (lc-SSc) (100.0%; cf. remainder, 75.3%; P < 0. 005), together with reduced incidences of both renal disease (2.4%, cf. remainder, 22.1%: P < 0.01) and pulmonary fibrosis (21.4%, cf. remainder, 52.3%; P < 0.005; RR 1.9). Anti-topo I antibodies were associated with the presence of pulmonary fibrosis (69.7%; cf. remainder, 32.6%; P < 0.001; RR 2.1). A majority of anti-topo I sera were from lc-SSc patients, regardless of whether anti-topo I antibodies occurred alone (75.0%) or together with anti-RNAP IIO + IIA antibodies (75.0%), and this was similar to the remainder (86. 5%; NS). However, when anti-topo I+ patients were compared with the ACA group, and then with all anti-RNAP I+ patients (37.5% lc-SSc), significant differences were found in the occurrence of dc- versus lc-SSc (P < 0.005 and P < 0.05, respectively). In conclusion, these results confirm that there are three main groups of SSc sera, each characterized by the presence of a mutually exclusive SSc-specific autoantibody (ACA, anti-topo I or anti-RNAP I), and distinguished by patterns of cutaneous involvement and specific clinical features. It appears that, in each of the three groups of SSc patients, distinct pathological processes are occurring, which are responsible for the characteristic symptoms, for the modification of particular autoantigens and, consequently, for the production of particular autoantibodies. Based on these data, together with our previous results, it is further hypothesized that anti-RNAP II antibodies may be produced in the context of two different immune response pathways.

Speech recognition after implantation of the ossified cochlea

OBJECTIVE

Insertion of complex, multichannel cochlear implant (CI) electrode arrays into ossified cochleas is now performed routinely. This study describes the hearing results obtained in a consecutive series of 21 patients with obstructed cochleas and compares these results to those in patients with open cochleas. The purpose of this study was to determine whether patients with ossification have speech perception results that are inferior to those of patients with no evidence of cochlear bone formation.

STUDY DESIGN

Retrospective analysis of consecutive clinical series.

METHODS

CI database review of 191 CI procedures at the University of Miami Ear Institute between 1990 and 1997 showed that 24 (13%) procedures were performed on patients with ossified cochleas. Open-set speech recognition scores obtained on the 11 pediatric and 7 adult English-speaking patients are compared to scores of 51 adult and 61 pediatric English-speaking CI patients with open scala.

RESULTS

Results of open-set speech recognition measures in adults and children with ossified cochleas were not significantly different from those of the reference groups.

CONCLUSION

Speech recognition results of patients with ossified cochleas are essentially equal to those of patients with open cochleas. Degree of obstruction appears to have less effect on outcome than other factors such as duration of profound deafness or communication methodology in children among this group.

Using the CLARION cochlear implant in cochlear ossification

This paper is a retrospective review of 5 patients with various degrees of cochlear ossification who were implanted with the CLARION Multi-Strategy Cochlear Implant. Preoperative computed tomography scans, intraoperative findings, surgical technique, and hearing outcomes are discussed in a case report format. Full implantation was achieved in all cases by a systematic approach that included drill-through of proximal obstruction (2 cases), scala vestibuli insertion (2 cases), and complete drill-out (1 case). The only complication was delayed wound healing in a patient with sickle cell disease, chronic active hepatitis, and steroid dependency on antimetabolite therapy. Early results show that the 4 patients with at least 3 months of experience have a mean open-set sentence recognition score of 55% and a mean open-set word recognition score of 24%. The conclusion is that implantation of the Clarion device in ossified cochleas can be successful in all degrees of ossification and can provide significant hearing benefit.

Using electrically evoked auditory reflex thresholds to fit the CLARION cochlear implant

This paper describes a method for measuring electrically elicited auditory reflex thresholds (EARTs) in young children who use the CLARION Multi-Strategy Cochlear Implant. The EART is an objective measure that can guide the fitting of a cochlear implant in individuals who are unable to perform behavioral tasks required to program the device. Reflexes were obtained in 11 of 17 pediatric Clarion users. The EART current level indicated a point at which an auditory percept was present and the sound was loud, but not uncomfortable. The EART then was used as a basis for conditioning behavioral responses, and as a guideline for setting most comfortable loudness levels.

Cochlear reimplantation

OBJECTIVE

A small number of multichannel cochlear implant (CI) recipients require reimplantation. This study describes the causes of failure, surgical technique, and hearing outcomes in a consecutive series of 16 patients undergoing reimplantation of multichannel devices. We hypothesize that reimplantation is safe and that hearing results are at least as good as those measured following primary implantation.

STUDY DESIGN

Retrospective analysis of consecutive clinical series.

METHODS

Chart analysis of 191 consecutive CI operations performed at the University of Miami Ear Institute between 1990 and 1997 revealed 16 patients who received a second multichannel device. All but one had a minimum follow-up of 1 year after reimplantation. Ten of these patients had initial implantation performed by us, and six were initially operated on elsewhere. Main outcomes of the initial procedure were compared with those of the reimplantation, including electrode insertion length, number of channels programmed, and audiometric results. In addition, cause of failure and relevant surgical findings at the second procedure are described.

RESULTS

There were no surgical complications after reimplantation surgery. Device failure was the most frequent cause for reimplantation. Time between initial implantation and failure ranged from 0 to 46 months (mean, 22.4 mo; median, 23 mo). Common intraoperative findings include mastoid fibrosis, bone growth at the cochleostomy, and skin flap breakdown. Following reimplantation, mean length of insertion, number of channels actively programmed, and speech recognition scores were at least as good as findings before initial implant failure.

CONCLUSION

CI reimplantation is safe and effective.

Hearing results with deep insertion of cochlear implant electrodes

OBJECTIVE

This study aimed to investigate the relationship of electrode insertion length and speech recognition in patients using Nucleus-22 cochlear implants.

STUDY DESIGN

The study design was a retrospective review of a consecutive clinical series.

SETTING

The study was conducted at an academic medical center.

PATIENTS

Thirty-one postlingually deafened adults with at least 6 months' experience with a Nucleus-22 cochlear implant using Spectra-22 processor and SPEAK strategy participated.

MAIN OUTCOME MEASURES

Open-set speech recognition scores for words and sentences were measured.

RESULTS

Insertion length ranged from 22 rings (estimated 17 mm) to 32 rings (estimated 25 mm). Mean word recognition score was 35%. Mean sentence score was 69.6%. Statistical analysis showed no correlation between insertion depth and word or sentence scores.

CONCLUSION

Insertion of the Nucleus-22 array beyond 22 rings does not improve performance in speech recognition. This finding cannot be generalized to other electrodes or processing strategies.