Higher testosterone is associated with higher HDL-cholesterol and lower triglyceride concentrations in older women: an observational study

OBJECTIVE

This study aimed to determine whether concentrations of testosterone and its main precursor after menopause, dehydroepiandrosterone (DHEA), are associated with lipoproteins and other lipids in community-dwelling older women.

METHODS

The Sex Hormones in Older Women (SHOW) study was an observational study of 6358 Australian women, aged at least 70 years, with no prior major adverse cardiovascular event who had sex hormones measured by liquid chromatography-tandem mass spectrometry. Associations between hormones and lipids were examined using multilinear regression adjusted for potential confounders.

RESULTS

The cross-sectional analyses included 3231 participants, median age 74.0 (interquartile range 71.7-77.9) years. Compared with concentrations in the lowest quartile (Q1), testosterone concentrations in the highest quartiles (Q3 and Q4) were positively associated with high-density lipoprotein cholesterol (HDL-C) (p = 0.002 and p < 0.001, respectively) while Q4 testosterone concentrations were positively associated with total cholesterol (p = 0.038). Q2, Q3 and Q4 testosterone concentrations were significantly inversely associated with triglycerides (TG) (p = 0.024, p = 0.003 and p < 0.001, respectively). For DHEA, Q4 concentrations was positively associated with non-HDL-C (p = 0.024).

CONCLUSIONS

In older women, higher endogenous testosterone concentrations are significantly associated with higher HDL-C and lower TG, indicating a less atherogenic profile. These findings suggest a neutral, or potentially protective, cardiovascular disease effect of testosterone in older women.

Testosterone and the heart: friend or foe?

Cardiovascular disease (CVD) is the leading cause of death in women aged 65 years and older. Sex hormones have been implicated as having a critical role in the evolution of CVD, with the focus mainly on estrogens in women. Available data also indicate that low testosterone blood levels may be detrimental to cardiovascular function in women. At blood concentrations considered normal for premenopausal women, testosterone has favorable effects on blood vessel function (relaxation and contraction), much of which is determined by the endothelial cells that line the inside of blood vessels. Testosterone enhances endothelium-dependent and independent brachial artery vasodilation and has an acute systolic blood pressure-lowering effect in postmenopausal women. Advantageous effects of testosterone in animal models have been seen for myocardial function and cardiac electrical signaling. Human data are mainly limited to observational and mechanistic studies, which mostly demonstrate beneficial effects of testosterone on cardiovascular health. Few studies of testosterone use in women, with cardiovascular endpoints as primary outcomes, have been published.

The 2023 Practitioner's Toolkit for Managing Menopause

OBJECTIVE

The Practitioner's Toolkit for Managing the Menopause, developed in 2014, provided an accessible desk-top tool for health-care practitioners caring for women at midlife. To ensure the Toolkit algorithms and supporting information reflect current best practice, the Toolkit has been revised in accordance with the published literature.

METHODS

A systematic search for guidelines, position and consensus statements pertaining to the menopause and published after 2014 was undertaken, and key recommendations extracted from the Clinical Practice Guidelines determined to be the most robust by formal evaluation. The peer-reviewed literature was further searched for identified information gaps.

RESULTS

The revised Toolkit provides algorithms that guide the clinical assessment and care of women relevant to menopause. Included are the reasons why women present, information that should be ascertained, issues that may influence shared decision-making and algorithms that assist with determination of menopausal status, menopause hormone therapy (MHT) and non-hormonal treatment options for symptom relief. As clear guidelines regarding when MHT might be indicated to prevent bone loss and subsequent osteoporosis in asymptomatic women were found to be lacking, the Toolkit has been expanded to support shared decision-making regarding bone health.

CONCLUSIONS

The 2023 Toolkit and supporting document provide accessible desk-top information to support health-care providers caring for women at midlife.The Toolkit has been endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean hailes for Women's Health.

Sex hormones, SHBG and cognitive performance among older Australian women: an observational study

OBJECTIVE

This study aims to explore the associations between sex hormones and cognitive performance in older women.

METHODS

Associations between sex hormones, sex hormone binding globulin (SHBG) and cognitive performance were examined in women aged at least 70 years, without dementia and not using medications that influence sex hormones. Linear and generalized linear regression models included age, body mass index, education, smoking, alcohol, living circumstances, diabetes, hypertension, depression and impaired renal function.

RESULTS

The included 5511 women had a median (interquartile range) age of 73.9 (71.6-77.6) years. No associations were found for estrone, estradiol, testosterone or dehydroepiandrosterone and cognitive performance. SHBG concentrations above quartile 1 (Q1) were significantly inversely associated with processing speed (Q2, β = -0.94, 95% confidence interval [CI] - 1.64 to -0.24, p = 0.009; Q3, β = -0.82, 95% CI -1.53 to -0.10, p = 0.025; and Q4, β = -0.95, 95% CI -1.70 to -0.20, p = 0.013).

CONCLUSIONS

Sex hormones were not associated with cognitive performance. The finding that low SHBG is associated with better processing speed warrants further investigation. The null findings for the sex hormones establish a firm baseline to confidently explore the association between sex hormones and longitudinal cognitive performance in this population.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number Register (ISRCTN83772183) and ClinicalTrials.gov (NCT01038583).

Estrone, sex hormone binding globulin and lipid profiles in older women: an observational study

OBJECTIVE

We investigated whether estrone and sex hormone binding globulin (SHBG) concentrations are associated with lipid concentrations in older postmenopausal women.

METHODS

This was a cross-sectional study of 6358 Australian women, aged 70-95 years, recruited between 2010 and 2014. Associations between estrone and SHBG and lipid concentrations were examined in participants not using medications that influence estrogen concentrations or lipid-lowering therapy. Linear regression models included age, body mass index, smoking, alcohol consumption, renal function and diabetes, with the lowest quartile (Q1) as the reference for estrone and SHBG.

RESULTS

The study included 3231 participants with median age of 74.0 (interquartile range 71.7-77.9) years. Estrone concentration Q3 and Q4 were positively associated with high-density lipoprotein cholesterol (HDL-C) (p = 0.017 and p = 0.046, respectively). Inverse associations were seen for estrone Q4 with total cholesterol (p = 0.018), Q2 and Q4 with non-HDL-C (p = 0.045 and p = 0.002, respectively) and Q3 and Q4 with triglycerides (p = 0.030 and p = 0.001, respectively). For SHBG, Q2, Q3 and Q4 were positively associated with HDL-C (all p < 0.001), and inversely with non-HDL-C (all p = 0.001) and triglycerides (all p < 0.001).

CONCLUSIONS

Estrone and SHBG are associated with lipid concentrations in older women. SHBG, but not estrone, may provide additional clinical predictive utility for the assessment of cardiometabolic disease risk in older women.

Menopause symptoms, sexual dysfunctions and pelvic floor disorders in refugee and asylum seeker women: a scoping review

Refugee and asylum seeker women face a variety of health challenges. However, little is known globally about health problems in these women at midlife and beyond, including menopausal symptoms, sexual dysfunctions and pelvic floor disorders. This scoping review aimed to understand these neglected health issues with respect to prevalence and risk factors. Eight databases were searched in August 2022 without the limit of publication year. Data were analyzed narratively. A total of 10 reports from seven studies were included with 945 women living in Australia, Canada, the USA and Pakistan. Three reports were addressing menopause, seven addressed sexual dysfunctions and one addressed pelvic floor disorders. There were no data regarding menopause symptoms; however, perceptions of menopause varied widely across studies. Few studies reported a high prevalence of sexual dysfunctions and pelvic organ prolapses, but none of them used a validated questionnaire. Taboos and cultural factors, lack of knowledge and education, lack of family support, language insufficiency and financial problems were common barriers to not seeking care for these health issues. This review demonstrates lack of evidence of these neglected health issues in refugee and asylum seeker women at midlife, and further studies with validated questionnaires and larger samples are warranted.

Association between testosterone and cognitive performance in postmenopausal women: a systematic review of observational studies

This review was conducted to explore the association between endogenous testosterone blood concentrations and cognitive performance among community dwelling postmenopausal women. We searched Ovid MEDLINE, EMBASE, PsycINFO and Web of Science databases for observational studies with at least 100 postmenopausal participants. The results were categorized by study design, reporting of total or free testosterone and risk of bias assessments, narratively. Ten of the 26 articles retrieved for full-text review met the inclusion criteria, six provided cross-sectional data, seven provided longitudinal data and one provided case-control data. Cognitive performance tests differed between studies. Eight studies measured testosterone by immunoassay, one by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and one did not specify their methodology. Eleven different cognitive domains were tested by 37 different instruments. Irrespective of the study design, the findings were inconsistent and inconclusive. Both positive and inverse associations were reported for each of global cognition and immediate and delayed verbal recall. The majority of studies reported no association between total or free testosterone and cognitive performance. Although this review did not demonstrate an association between testosterone and cognitive performance in postmenopausal women, the findings should be considered inconclusive due to the imprecision of testosterone measurement and the methodological heterogeneity of the included studies.

Testosterone for women: certainties and uncertainties

The clinical effects of testosterone in women have expanded from the field of androgen excess to consideration of testosterone action and the consequences of depletion and replacement. This article is not a comprehensive review of the vast and increasing literature in this field. Rather, it summarizes some of what is known of testosterone in women that the author elected to highlight in a plenary lecture and is hopefully informative, but not to be considered conclusive.

Impact of Interfacing Near Point of Care Clinical Chemistry and Hematology Analyzers at Urgent Care Clinics at an Academic Health System

Background

Point-of-care (POC) testing equipment is commonly utilized in outpatient clinics. Our institution recently interfaced POC chemistry and hematology devices at two outpatient clinics via middleware software to the central electronic health record (EHR), facilitating a comparison of manual transcription versus automatic reporting via interface. This allowed for estimation of serious/obvious error rates and manual time savings. Additional goals were to develop autoverification rules and analyze broad trends of results in response to common clinician complaints on the POC testing.

Material and Methods

Data were obtained from two satellite clinic sites providing both primary and urgent care within an academic health system. Interface of devices was accomplished via Instrument Manager middleware software and occurred approximately halfway through the 38 month retrospective timeframe. Laboratory results for three testing POC chemistry and hematology panels were extracted with EHR tools.

Results

Nearly 100,000 lab values were analyzed and revealed that the rate of laboratory values outside reference range was essentially unchanged before and after interface of POC testing devices (2.0–2.1%). Serious/obvious errors, while rare overall, declined significantly, with none recorded after the interface with autoverified results and only three related to manual edits of results that failed autoverification. Fewer duplicated test results were identified after the interface, most notably with the hematology testing. Anion gap values of less than zero were observed more frequently in POC device tests when compared to central laboratory tests and are attributed to a higher proportion of Cl values greater than 110 mEq/L and CO₂ values greater than 30 mEq/L with POC results. Time savings of eliminating manual data entry were calculated to be 21.6 employee hours per month.

Conclusions

In a switch from manual entry to automatic interface for POC chemistry and hematology, the most notable changes were reduction of serious/obvious errors and duplicate results. Significant time employee time savings highlight an additional benefit of instrument interfacing. Lastly, a difference between POC and central laboratory instruments is a higher rate of high Cl and CO₂ values relative to the central laboratory.

Pregnancy status predicted using milk mid-infrared spectra from dairy cattle

Accurate and timely pregnancy diagnosis is an important component of effective herd management in dairy cattle. Predicting pregnancy from Fourier-transform mid-infrared (FT-MIR) spectroscopy data is of particular interest because the data are often already available from routine milk testing. The purpose of this study was to evaluate how well pregnancy status could be predicted in a large data set of 1,161,436 FT-MIR milk spectra records from 863,982 mixed-breed pasture-based New Zealand dairy cattle managed within seasonal calving systems. Three strategies were assessed for defining the nonpregnant cows when partitioning the records according to pregnancy status in the training population. Two of these used records for cows with a subsequent calving only, whereas the third also included records for cows without a subsequent calving. For each partitioning strategy, partial least squares discriminant analysis models were developed, whereby spectra from all the cows in 80% of herds were used to train the models, and predictions on cows in the remaining herds were used for validation. A separate data set was also used as a secondary validation, whereby pregnancy diagnosis had been assigned according to the presence of pregnancy-associated glycoproteins (PAG) in the milk samples. We examined different ways of accounting for stage of lactation in the prediction models, either by including it as an effect in the prediction model, or by pre-adjusting spectra before fitting the model. For a subset of strategies, we also assessed prediction accuracies from deep learning approaches, utilizing either the raw spectra or images of spectra. Across all strategies, prediction accuracies were highest for models using the unadjusted spectra as model predictors. Strategies for cows with a subsequent calving performed well in herd-independent validation with sensitivities above 0.79, specificities above 0.91 and area under the receiver operating characteristic curve (AUC) values over 0.91. However, for these strategies, the specificity to predict nonpregnant cows in the external PAG data set was poor (0.002-0.04). The best performing models were those that included records for cows without a subsequent calving, and used unadjusted spectra and days in milk as predictors, with consistent results observed across the training, herd-independent validation and PAG data sets. For the partial least squares discriminant analysis model, sensitivity was 0.71, specificity was 0.54 and AUC values were 0.68 in the PAG data set; and for an image-based deep learning model, the sensitivity was 0.74, specificity was 0.52 and the AUC value was 0.69. Our results demonstrate that in pasture-based seasonal calving herds, confounding between pregnancy status and spectral changes associated with stage of lactation can inflate prediction accuracies. When the effect of this confounding was reduced, prediction accuracies were not sufficiently high enough to use as a sole indicator of pregnancy status.

An observational study on the relationship between zinc concentrations in bulk tank milk and in serum and farmer-reported zinc supplementation of dairy cattle for facial eczema prophylaxis

AIMS

To describe the concentration of Zn in bulk tank milk (BTM) in a sample of New Zealand dairy farms, investigate the association between the method of Zn administration for facial eczema prophylaxis and Zn concentrations in BTM and investigate the relationship between the concentration of Zn in serum and that in BTM.

METHODS

Multiple BTM samples (n = 3,330) collected during milk pick-up by the milk tanker driver were stored and tested for 121 farms, in Northland (n = 50), Waikato (n = 51) and Southland (n = 20) from February to May 2017. Enrolled farms provided retrospective information on the type of Zn supplementation (if any) used for the prevention of facial eczema and the timeframe over which supplementation occurred. In addition, the concentration of Zn in serum was measured in blood samples collected from ≥15 cattle per farm for 22 farms from Northland (n = 11) and Waikato (n = 11), and compared against the concentrations of Zn in BTM on the day of blood sampling. A linear mixed model was used to model log Zn concentrations in BTM using method of Zn supplementation, region, milk fat and protein percentage, volume of milk, and frequency of milk pick-up as risk factors. A mixed logistic regression model was used to assess the relationship between Zn concentrations in BTM and the presence of cows with a concentration of Zn in serum of ≥20 µmol/L.

RESULTS

The median Zn concentration in BTM was 67.9 (min 38.9, max 146.6) µmol/L. The median range of Zn concentrations for repeated samples of BTM within farm was 22.6 µmol/L. In comparison to farms that did not use any form of Zn supplementation, farms that supplemented Zn through a slow-release capsule, oral drench, in feed or a combination of in-feed and water were associated with increased concentrations of Zn in BTM (p < 0.001). There was no difference in Zn concentrations in BTM between farms that administered Zn through the water only and farms that did not administer Zn (p = 0.22). Every 15.3 μmol/L increase in Zn concentration in BTM was associated with 2.2 times (95% CI=1.7-2.9) the odds of a cow having Zn concentration in serum ≥20 μmol/L.

CONCLUSION AND CLINICAL RELEVANCE

Zn concentration in BTM is highly variable between farms, days and Zn administration method. Zn concentration in BTM content has modest potential as a way to signal whether a herd has achieved the high Zn status considered to be protective against FE.

Quantification of zinc concentrations in serum, milk and faeces of dairy cattle as a measure of effective zinc supplementation for management of facial eczema

AIMS

To investigate the relationship between Zn concentrations in serum and those in milk or faeces, and to assess the ability of the Zn concentrations in milk, serum and faeces to predict intake of ZnO in dairy cattle.

METHOD

Seventy cows from one commercial farm in the Waikato region of New Zealand received one of seven dose rates (0, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5 g/100 kg bodyweight (BW)) of ZnO given by oral drench, every morning, for 7 consecutive days. Every afternoon, milk and blood samples were collected from all cows. Free-catch faecal samples were collected during the afternoon milking on 3 days throughout the trial.Linear mixed models were used to assess the relationship between the concentration of Zn in serum and that in milk, and in faeces, respectively, and the relationship between dose rate of ZnO and concentrations of Zn in serum, faeces and milk, respectively. Receiver operating characteristic curve analysis was used to determine the ability of the Zn concentration in serum, milk and faeces to predict that a cow had been treated with a dose of ZnO ≥2.5 g/100 kg, the industry-recommended dose rate needed to protect against facial eczema.

RESULTS

A 1-µmol/L increase in Zn concentration in milk was associated with a 0.14 (95% CI = 0.11-0.17) µmol/L increase in Zn concentration in serum. Zn concentration in faeces was scaled by its SD; a 1 SD increase was associated with a 1.83 (95% CI = 0.54-3.12) µmol/L increase in zinc concentration in serum. Zn concentrations in serum and faeces increased with increasing dose rates of ZnO. No differences in Zn concentrations in milk were noted between animals dosed with 1.5-3.5 g ZnO/100 kg BW, inclusive. At the optimal threshold of Zn concentration in serum to predict protective ZnO intake (22 µmol/L), the sensitivity was 0.76 (95% CI = 0.69-0.82) and specificity 0.85 (95% CI = 0.80-0.89). For the concentration of Zn in faeces, the optimal threshold was 17.36 mmol/kg, with a corresponding sensitivity of 0.84 (95% CI = 0.84-0.85) and specificity of 0.85 (95% CI = 0.73-0.94). At the optimal threshold for the Zn concentration in milk (76.6 µmol/L), the sensitivity was lower than the other two sample types at 0.59 (95% CI = 0.52-0.67), but with a similar specificity of 0.84 (95% CI = 0.79-0.88).

CONCLUSIONS AND CLINICAL RELEVANCE

The concentration of Zn in milk shows promise as an initial screening test to identify dairy farms that do not provide adequate zinc to provide protection against FE.

Health-care providers' views of menopause and its management: a qualitative study

OBJECTIVE

This study aimed to explore Australian health-care providers' knowledge of menopause and its consequences, and their views about menopause-related health care.

METHODS

This was a cross-sectional qualitative study of Australian general practitioners (GPs), gynecologists (GYs) and pharmacists (PHs). Recruitment was ultimately achieved through professional networks and cold calling.

RESULTS

There were equal numbers of GPs, GYs and PHs, and equal numbers of males and females in each group. All participants demonstrated sound understanding of menopause and its consequences. A strong theme was recognition of high usage of complementary and alternative medicines (CAMs) by women for menopausal symptoms. Most participants highlighted lack of efficacy evidence for most CAMs, but the majority of GPs and PHs considered CAMs to 'have a role'. Most supported menopausal hormone therapy (MHT) when symptoms impaired quality of life. Limitations to comprehensive care included knowledge gaps and lack of time.

CONCLUSIONS

Australian health-care providers appeared knowledgeable about menopause, but uncertain about its management. MHT prescription appeared limited to women with severe symptoms despite lifestyle modification and a trial of CAMs. The upskilling of clinicians providing care for women at midlife, with respect to the indications for and prescribing of MHT, urgently needs to be addressed.

Use of Middleware Data to Dissect and Optimize Hematology Autoverification

Background:

Hematology analysis comprises some of the highest volume tests run in clinical laboratories. Autoverification of hematology results using computer-based rules reduces turnaround time for many specimens, while strategically targeting specimen review by technologist or pathologist.

Methods:

Autoverification rules had been developed over a decade at an 800-bed tertiary/quarternary care academic medical central laboratory serving both adult and pediatric populations. In the process of migrating to newer hematology instruments, we analyzed the rates of the autoverification rules/flags most commonly associated with triggering manual review. We were particularly interested in rules that on their own often led to manual review in the absence of other flags. Prior to the study, autoverification rates were 87.8% (out of 16,073 orders) for complete blood count (CBC) if ordered as a panel and 85.8% (out of 1,940 orders) for CBC components ordered individually (not as the panel).

Results:

Detailed analysis of rules/flags that frequently triggered indicated that the immature granulocyte (IG) flag (an instrument parameter) and rules that reflexed platelet by impedance method (PLT-I) to platelet by fluorescent method (PLT-F) represented the two biggest opportunities to increase autoverification. The IG flag threshold had previously been validated at 2%, a setting that resulted in this flag alone preventing autoverification in 6.0% of all samples. The IG flag threshold was raised to 5% after detailed chart review; this was also the instrument vendor's default recommendation for the newer hematology analyzers. Analysis also supported switching to PLT-F for all platelet analysis. Autoverification rates increased to 93.5% (out of 91,692 orders) for CBC as a panel and 89.8% (out of 11,982 orders) for individual components after changes in rules and laboratory practice.

Conclusions:

Detailed analysis of autoverification of hematology testing at an academic medical center clinical laboratory that had been using a set of autoverification rules for over a decade revealed opportunities to optimize the parameters. The data analysis was challenging and time-consuming, highlighting opportunities for improvement in software tools that allow for more rapid and routine evaluation of autoverification parameters.

Androgens in premenopausal women and women with premature ovarian insufficiency

Premature ovarian insufficiency (POI) results in both estrogen and testosterone insufficiency. Whether testosterone therapy may be of benefit for women with POI is uncertain. Presently, the only evidence-based indication for testosterone therapy for women is for the treatment of postmenopausal women with low sexual desire with associated personal distress. Consistent with this, available evidence does not support the prescription of testosterone to prevent cardiometabolic disease, bone loss, sarcopenia, or cognitive decline or to improve well-being and low mood in postmenopausal women. Data pertaining to the treatment of women with POI with testosterone are limited. This article reviews androgen physiology in premenopausal women and the impact of POI on circulating androgen concentrations, summarizes findings from observational studies and clinical trials of testosterone therapy in premenopausal women and women with POI, and concludes with recommendations regarding testosterone use in women with POI.

Data on length of parathyroidectomy surgery and intraoperative parathyroid hormone (PTH) assay turnaround times following a switch in the location for intraoperative PTH testing from near point-of-care to central laboratory

Intraoperative monitoring of parathyroid hormone (PTH) is commonly used during parathyroidectomies. There are a number of practical challenges in achieving rapid turnaround time (TAT) for intraoperative PTH testing, whether the testing is performed point-of-care, near point-of-care, or in a central clinical laboratory. In the related research article, we analyzed a decade of data from 3025 intraoperative PTH tests on 897 unique patients. Of these, 1787 tests on 514 unique patients (375 female, 139 male) occurred while intraoperative PTH measurement was done as near point-of-care testing; the remaining 1238 tests on 383 unique patients (282 female, 101 male) occurred after a switch to intraoperative PTH measurement by the hospital central laboratory. The data in this article provides the patient age, gender, location of surgery (main operating rooms vs. ambulatory surgery center), incision to close time for surgery, and operation start to end times. For the central laboratory testing, additional data are provided for the intraoperative PTH TAT. The analyzed data is provided in the supplementary tables included in this article. Plots of operation start and end times are also included. The dataset reported is related to the research article entitled "Evaluation of Switch from Satellite Laboratory to Central Laboratory for Testing of Intraoperative Parathyroid Hormone" [D. Jacob, G. Lal, D.R. Voss, T. Bebber, S.R. David, J. Kulhavy, S.L. Sugg, A.E. Merrill, M.D. Krasowski, Evaluation of Switch from Satellite Laboratory to Central Laboratory for Testing of Intraoperative Parathyroid Hormone, Pract. Lab. Med. (2020) 22: e00176] [1].

Evaluation of switch from satellite laboratory to central laboratory for testing of intraoperative parathyroid hormone

Objectives

The aim of this study was to evaluate testing turnaround time (TAT) and incision to close time in parathyroid surgeries before and after switching intraoperative parathyroid hormone (PTH) testing from a near point of care location to a central clinical laboratory.

Design and Methods

This retrospective study covered a ten-year period. Both testing locations used the same Roche Diagnostics PTH immunoassay but on different analyzers. The predominant site for surgeries was the main operating rooms (ORs) in an adjacent building, with a limited number of parathyroid surgeries performed at a more distant ambulatory surgery center (ASC). Under ideal conditions, TAT for near point-of-care testing was 20 ​min, although multiple factors could increase TAT. Incision to close time from the electronic health record was used to define time of surgery.

Results

A total of 897 unique patients were identified for which 3031 orders for intraoperative PTH were placed (383 unique patients and 1244 orders after switch in testing site). The average total TAT times for testing (mean ​± ​SD) in the central laboratory were 23.9 ​± ​16.0 ​min (median, 22 ​min) for all specimens, 22.8 ​± ​7.9 ​min (median, 21 ​min) for main OR specimens, and 26.4 ​± ​7.1 ​min (median, 25 ​min) for ASC specimens. Incision to close time for parathyroidectomies showed decreases in mean, median, and standard deviation following testing change.

Conclusions

Surgery time for parathyroidectomies may remain consistent or decrease if intraoperative PTH testing is moved from a near point of care to a central laboratory.

•

Turnaround around time for intraoperative parathyroid hormone (PTH) analysis in a central laboratory was evaluated.

•

Surgery incision to close times were compared to 514 surgeries with intraoperative PTH performed as near point of care.

•

Pre-analytical factors, especially transport time, were the major variable impacting turnaround time.

•

The mean, median, and standard deviation for surgery incision to close times decreased in the switch to the central laboratory.

Testosterone use in postmenopausal women

The physiological, clinical and therapeutic aspects of testosterone in women's health are still a matter of controversy and debate. Quality evidence data of clinical trials favors the use of transdermal testosterone in postmenopausal women with female sexual dysfunction causing distress. Doses of testosterone should approximate physiological testosterone levels found in premenopausal women, avoiding supraphysiological concentrations that expose women to adverse events. Short-term treatment periods have been shown to be effective and safe in postmenopausal women with hypoactive sexual desire disorder/dysfunction. However, long-term safety of testosterone use must be determined.

Genetic correlations of milk fatty acid contents predicted from milk mid-infrared spectra in New Zealand dairy cattle

The objective of this study was to estimate genetic correlations among milk fatty acid (FA) concentrations in New Zealand dairy cattle. Concentrations of each of the most common FA, expressed as a percentage of the total FA, were determined by gas chromatography on a specific cohort of animals. Using this data set, prediction equations were derived using mid-infrared (MIR) spectroscopy data collected from the same samples. These prediction equations were applied to a large data set of MIR measurements in 34,141 milk samples from 3,445 Holstein-Friesian, 2,935 Jersey, and 3,609 crossbred Holstein-Friesian × Jersey cows, sampled an average of 3.42 times during the 2007-2008 season. Data were analyzed using univariate and bivariate repeatability animal models. Heritability of predicted FA concentration in milk fat ranged from 0.21 to 0.42, indicating that genetic selection could be used to change the FA composition of milk. The de novo synthesized FA (C6:0, C8:0, C10:0, C12:0, and C14:0) showed strong positive genetic correlations with each other, ranging from 0.24 to 0.99. Saturated FA were negatively correlated with unsaturated (-0.93) and polyunsaturated (-0.84) FA. The saturated FA were positively correlated with milk fat yield and fat percentage, whereas the unsaturated FA were negatively associated with fat yield and fat percentage. Our results indicate that bovine milk FA composition can be changed through genetic selection using MIR as a phenotypic proxy.

Strategies for noise reduction and standardization of milk mid-infrared spectra from dairy cattle

The use of Fourier-transform mid-infrared (FTIR) spectroscopy is of interest to the dairy industry worldwide for predicting milk composition and other novel traits that are difficult or expensive to measure directly. Although there are many valuable applications for FTIR spectra, noise from differences in spectral responses between instruments is problematic because it reduces prediction accuracy if ignored. The purpose of this study was to develop strategies to reduce the impact of noise and to compare methods for standardizing FTIR spectra in order to reduce between-instrument variability in multiple-instrument networks. Noise levels in bands of the infrared spectrum caused by the water content of milk were characterized, and a method for identifying and removing outliers was developed. Two standardization methods were assessed and compared: piecewise direct standardization (PDS), which related spectra on a primary instrument to spectra on 5 other (secondary) instruments using identical milk-based reference samples (n = 918) analyzed across the 6 instruments; and retroactive percentile standardization (RPS), whereby percentiles of observed spectra from routine milk test samples (n = 2,044,094) were used to map and exploit primary- and secondary-instrument relationships. Different applications of each method were studied to determine the optimal way to implement each method across time. Industry-standard predictions of milk components from 2,044,094 spectra records were regressed against predictions from spectra before and after standardization using PDS or RPS. The PDS approach resulted in an overall decrease in root mean square error between industry-standard predictions and predictions from spectra from 0.190 to 0.071 g/100 mL for fat, from 0.129 to 0.055 g/100 mL for protein, and from 0.143 to 0.088 g/100 mL for lactose. Reductions in prediction error for RPS were similar but less consistent than those for PDS across time, but similar reductions were achieved when PDS coefficients were updated monthly and separate primary instruments were assigned for the North and South Islands of New Zealand. We demonstrated that the PDS approach is the most consistent method to reduce prediction errors across time. We also showed that the RPS approach is sensitive to shifts in milk composition but can be used to reduce prediction errors, provided that secondary-instrument spectra are standardized to a primary instrument with samples of broadly equivalent milk composition. Appropriate implementation of either of these approaches will improve the quality of predictions based on FTIR spectra for various downstream applications.

Short communication: Identification of the pseudoautosomal region in the Hereford bovine reference genome assembly ARS-UCD1.2

In cattle, the X chromosome accounts for approximately 3 and 6% of the genome in bulls and cows, respectively. In spite of the large size of this chromosome, very few studies report analysis of the X chromosome in genome-wide association studies and genomic selection. This lack of genetic interrogation is likely due to the complexities of undertaking these studies given the hemizygous state of some, but not all, of the X chromosome in males. The first step in facilitating analysis of this gene-rich chromosome is to accurately identify coordinates for the pseudoautosomal boundary (PAB) to split the chromosome into a region that may be treated as autosomal sequence (pseudoautosomal region) and a region that requires more complex statistical models. With the recent release of ARS-UCD1.2, a more complete and accurate assembly of the cattle genome than was previously available, it is timely to fine map the PAB for the first time. Here we report the use of SNP chip genotypes, short-read sequences, and long-read sequences to fine map the PAB (X chromosome:133,300,518) and simultaneously determine the neighboring regions of reduced homology and true pseudoautosomal region. These results greatly facilitate the inclusion of the X chromosome in genome-wide association studies, genomic selection, and other genetic analysis undertaken on this reference genome.

Bothersome menopausal symptoms amongst postmenopausal Iranian women

OBJECTIVES

This study was undertaken to determine the impact of menopause on middle-eastern women.

METHODS

This was a cross-sectional study of 1520 women, aged 40-64 years, living in Sari, Northern Iran, recruited by multistage cluster sampling between October 2016 and April 2017. All women completed the Menopause Quality of Life Questionnaire (MENQOL) and Beck Depression Inventory-II (BDI-II).

RESULTS

Of all the women, 54.5% were perimenopausal or postmenopausal. The prevalences of any vasomotor symptom (VMS) and moderate-severely bothersome VMS were greatest for postmenopausal women aged <55 years (66.4%, 95% confidence interval (CI) 59.9-72.3% and 13.5%, 95% CI 9.6-18.6%, respectively). Having moderate-severe VMS was associated with moderate-severe depressive symptoms (adjusted odds ratio (AOR) 2.9; 95% CI 1.6-5.2; p < 0.001). Symptoms of vulvovaginal atrophy (VVA) were reported by 41.1% (95% CI 37.4-45.0%) of perimenopausal and postmenopausal women, with 22.9% (95% CI 19.8-26.3%) reporting their symptoms as moderate-severely bothersome. In women with moderate-severe VMS, the proportion with both moderate-severe depressive symptoms and moderate-severe VVA symptoms (12.1%) was four times that in women with no or mild VMS (3.3%) (p < 0.001).

CONCLUSION

One in seven perimenopausal and postmenopausal women has moderate-severely bothersome VMS and few women receive appropriate therapy. The reporting of moderate-severe VMS should alert clinicians to the likelihood of significant concurrent VVA and depressive symptoms.

Impact of Daylight Saving Time on the Clinical Laboratory

Daylight saving time is a practice in some countries and local regions to set clocks forward (typically 1 hour) during the longer days of summer and back again in autumn. Time changes resulting from daylight saving time have the potential to impact clinical laboratory instruments, computer interfaces, and information systems. We analyzed turnaround time data for an academic medical center clinical laboratories (chemistry, hematology, blood gas analyzer, and transfusion medicine), examining how turnaround time was impacted by the daylight saving time shifts in 2017. We also determined whether the daylight saving time shift on November 5, 2017 (“fall back” by 1 hour) resulted in any “absurd” time combinations such as a receipt time occurring “before” a normally later time such as final result. We also describe challenges resulting from daylight saving time changes over a 5-year period. The only significant impact on turnaround time was for clinical chemistry samples during the autumn daylight saving time change, but the overall impact was low. Four instances of absurd time combinations occurred in the autumn time change with only a transfusion medicine example resulting in an interface error (a Type and Screen resulted “before” receipt in laboratory). Over a 5-year period, other daylight saving time impacts included problems of reestablishing interface to instruments, inadvertent discrepancies in manual time changes at different points of the core laboratory automation line, and time change errors in instruments with older operating systems lacking patches that updated daylight saving time rules after 2007. Clinical laboratories should be aware that rare problems may occur due to issues with daylight saving time changes.

TRIENNIAL LACTATION SYMPOSIUM/BOLFA: Mammary growth during pregnancy and lactation and its relationship with milk yield

The number of secretory cells in the mammary gland is often cited as a major determinant of milk production. However, literature data for proxy measures of secretory cell number do not fully support such a claim. In particular, measurements of total mammary DNA in livestock explain only <25% of variation in milk yield, probably because of tissue heterogeneity for DNA concentration. Relative to BW, measurements of udder size in dairy cattle, as total DNA or udder weight, are approximately double those seen in most other livestock classes. Therefore, selection for dairy production, not surprisingly, has resulted in cows with greater secretory capacity. There is limited evidence that genetic selection is still increasing udder size in some cattle populations, but more recent data are needed. It is contended that the most important period of mammary growth for determination of milk yield is that occurring in pregnancy and early lactation. Mammary development is largely complete, at term, in sheep, goats, and cattle, but in pigs, the udder continues to grow during the first 3 wk of lactation, depending, in part, on litter size. Increased litter size in sheep and goats will enhance the extent of mammary development at the end of gestation (and milk yield) by 20 to 25%. However, twinning in dairy cattle does not affect milk production and, by inference only, is not likely to affect numbers of secretory cells at term. Milking frequency and suckling intensity in very early lactation will increase milk yield in cows and increase mammogenesis and milk yield in sheep, indicating that even at term, the ruminant gland retains some capacity for further development, if demand requires it. There is limited understanding of the hormonal signals in pregnancy that regulate mammary development relative to the number of young carried. Furthermore, the genetic differences between dairy and beef cattle that lead to substantially greater udder size in the dairy breeds have not been identified. During lactation, the drivers for secretory cell loss in relation to milking frequency and nutritional status are still not known. Measurement of mammary development and using this phenotype in genomewide association studies to identify key genetic variants for mammogenesis will provide knowledge that is fundamental to understanding the quantitative regulation of milk production.

Prevalence and Clinical Utility of "Incidental" Critical Values Resulting From Critical Care Laboratory Testing

OBJECTIVE

Panels of clinical laboratory testing may generate "incidental" critical values from unordered parameters. Existing regulations do not clearly delineate guidelines for handling incidental critical values. The objective of this study was to examine the patterns and clinical utility of incidental critical values at 2 critical care laboratories within an academic medical center.

METHODS

In this retrospective study, the electronic health record and laboratory information system were reviewed for incidental critical results obtained from blood gas analyzer analysis of whole blood specimens between November 2010 and August 2014.

RESULTS

Within the retrospective time period, 9,092 incidental critical results were documented, of which only 11.8% were added to the "parent" order following clinical notification. Incidental critical results frequently occurred in patients who had recent critical values for the same parameter.

CONCLUSION

In this study, at an academic medical center, incidental critical values associated with blood gas analyzers were added on at a low rate and often provided redundant information. Relative to the manual effort involved in care providers' notification and documentation of results, incidental critical values appear to have low clinical utility.

Depressive symptoms and their risk factors in midlife women in the Middle East: a systematic review

INTRODUCTION

Women may experience different menopausal symptoms across different cultures around the world. The purpose of this study was to determine the prevalence and contributing factors of depression in midlife women in the Middle East.

METHODS

Electronic databases including PubMed, Medline, PsycINFO, CINAHL, Web of Science, SCOPUS, and Google scholar were searched. The quality of articles was assessed by using the risk of bias tool.

RESULTS

Sixteen articles were used for this review. The prevalence for depressive symptoms in perimenopausal women is higher than in premenopausal women. The overall data also suggest that depressive symptoms may be more prevalent in postmenopausal women than in premenopausal women. Studies reported sociodemographic, physical, psychological, cultural and sexual risk factors for depressive symptoms in middle-aged women. Risk of bias for a majority of the studies conducted in the Middle Eastern region on depression in midlife was moderate.

CONCLUSION

Consistent with other areas in the world, midlife women in the Middle East region are at higher risk for depression due to the presence of different factors. High-quality longitudinal studies of representative samples, using validated questionnaires, are needed to provide more accurate prevalence data and the association between menopause and menopausal symptoms in women in the Middle East.

"Kiss myAsthma": Using a participatory design approach to develop a self-management app with young people with asthma

Objective: Young people with asthma often lack engagement in self-management. Smartphone apps offer an attractive, immediate method for obtaining asthma information and self-management support. In this research we developed an evidence-based asthma app tailored to young peoples needs, created using a participatory design approach to optimize user engagement. This paper describes the participatory design process. Methods: This multi-phased research included concept generation and ideation of app design by young people with asthma, and development of asthma information by the research team. Clinical review was sought regarding safety and accuracy of app content. Participants suggestions for improvement and any problems with the app were logged throughout. Our young co-designers were invited back to test a high fidelity prototype app using a "think aloud" process and completed a usability questionnaire. Results: Twenty asthma patients aged 15-24 years contributed to the initial app design. Three respiratory specialists and two pharmacists suggested minor corrections to clinical terminology in the app which were all incorporated. Nine co-designers acted as expert reviewers of the prototype app, of whom eight completed a usability questionnaire. Median usability scores (maximum score 6) indicated high satisfaction with app content, usefulness and ease of use [median item score 5.3 (range 4.7-6.0)]. All feedback was incorporated to create an updated prototype app. Conclusions: A clinically sound asthma app has been developed which is considered highly acceptable to the young co-designers. A six-week test of the engagement, acceptability, and usefulness of the app in young people not involved in the participatory design will follow.

Use of a Rapid Ethylene Glycol Assay: a 4-Year Retrospective Study at an Academic Medical Center

Ethylene glycol (EG) is a common cause of toxic ingestions. Gas chromatography (GC)-based laboratory assays are the gold standard for diagnosing EG intoxication. However, GC requires specialized instrumentation and technical expertise that limits feasibility for many clinical laboratories. The objective of this retrospective study was to determine the utility of incorporating a rapid EG assay for management of cases with suspected EG poisoning. The University of Iowa Hospitals and Clinics core clinical laboratory adapted a veterinary EG assay (Catachem, Inc.) for the Roche Diagnostics cobas 8000 c502 analyzer and incorporated this assay in an osmolal gap-based algorithm for potential toxic alcohol/glycol ingestions. The main limitation is that high concentrations of propylene glycol (PG), while readily identifiable by reaction rate kinetics, can interfere with EG measurement. The clinical laboratory had the ability to perform GC for EG and PG, if needed. A total of 222 rapid EG and 24 EG/PG GC analyses were documented in 106 patient encounters. Of ten confirmed EG ingestions, eight cases were managed entirely with the rapid EG assay. PG interference was evident in 25 samples, leading to 8 GC analyses to rule out the presence of EG. Chart review of cases with negative rapid EG assay results showed no evidence of false negatives. The results of this study highlight the use of incorporating a rapid EG assay for the diagnosis and management of suspected EG toxicity by decreasing the reliance on GC. Future improvements would involve rapid EG assays that completely avoid interference by PG.

BREEDING AND GENETICS SYMPOSIUM:Breeding heat tolerant dairy cattle: the case for introgression of the "slick" prolactin receptor variant into dairy breeds

Increasing environmental temperatures are a threat to the sustainability of livestock production and, because of the high metabolic demands of lactation, to dairy production in particular. Summer heat waves in temperate climates reduce feed intake, milk production, and cow comfort. In extreme heat events, there is an increase in cow mortality. In tropical climates, dairy cattle are mostly (zebu) type or zebu crossbred with temperate dairy breeds. Crossbreeding is undertaken to combine the heat tolerance and tick resistance of zebu with the productivity of temperate dairy breeds. In the absence of improved heat tolerance, milk production and fertility of temperate cattle is severely impaired. We have recently identified a key role for the prolactin pathway in regulating heat tolerance. A de novo mutation in prolactin that impairs prolactin activity was discovered in hairy and heat intolerant, New Zealand dairy cattle. The phenotypes produced were remarkably similar to those seen in fescue toxicosis, a syndrome seen in grazing cattle in the U.S. where ingestion of ergovaline, a fungal toxin from infected pasture, inhibits prolactin secretion. Recognition of the role of prolactin in hairy cattle led us to identify a deletion in exon 10 of the long-form of the prolactin receptor in Senepol cattle that causes truncation of the protein and determines the slick coat and heat tolerance traits found in this , beef breed. The short form of the prolactin receptor is predicted to be unaffected by the deletion. Knowledge of this dominant mutation has provided the impetus to begin a crossbreeding program to investigate performance and heat tolerance of temperate dairy cattle carrying the slick, prolactin receptor variant. The perceived opportunity is to introgress this variant into temperate dairy cattle to enable performance and welfare improvement in hot climates. Heat tolerance of cattle with slick coats appears to be mostly associated with coat type although sweating ability may also be enhanced. Further investigation is required of performance traits in cows homozygous for the slick variant because the published data are almost exclusively from heterozygous animals. Combination of the slick mutation with other favorable genes for heat tolerance, especially those for coat color, will be particularly enabled by gene editing technologies, offering opportunities for further improvement in bovine thermotolerance.

Impact of Endogenous and Exogenous Interferences on Clinical Chemistry Parameters Measured on Blood Gas Analyzers

BACKGROUND

The prevalence of hemolysis, icterus, and lipemia (HIL) was determined for residual whole blood specimens analyzed for clinical chemistry parameters on blood gas analyzers. The frequency and potential impact of exogenous interference from iodide, salicylate, and thiocyanate (metabolite of sodium nitroprusside) on analysis of whole blood chloride was also assessed.

METHODS

Over an approximately two month period at an academic medical center, indices for HIL were determined on Roche cobas c502 analyzers for 1,986 residual whole blood specimens that had been previously analyzed for clinical chemistry parameters on Radiometer ABL90 FLEX blood gas analyzers. To examine exogenous interferences, retrospective analysis was performed over multiple years to ascertain whether patient samples analyzed for whole blood chloride were potentially affected by interference from iodide, salicylate, or thiocyanate.

RESULTS

Some degree of hemolysis (defined as hemolysis index of greater than 60) was present in 9.7% of the whole blood specimens. Increasing rates of hemolysis were associated with higher whole blood potassium concentrations. Nearly 60% of specimens with potassium concentrations between 6.0 and 6.9 mEq/L had hemolysis indices of 100 or greater, and 75% of specimens with a potassium concentration of 7.0 mEq/L or greater were severely hemolyzed (hemolysis index of 300 or greater). In contrast to the hemolysis results, icterus and lipemia were determined to have minimal impact on patient results. For the exogenous interferences, we did not identify any patient samples where elevated salicylate levels or pharmaceutical iodide administration overlapped with whole blood chloride analysis (out of 75,887 and 169,229 total chloride measurements, respectively). We did, however, find that for patients receiving nitroprusside therapy in the inpatient setting, whole blood chloride concentrations were significantly higher during nitroprusside therapy [106.7 +/- 6.2 mEq/L (mean, SD)] compared to before or after nitroprusside therapy (103.1 +/- 7.7 mEq/L).

CONCLUSIONS

In this analysis of whole blood specimens, hemolysis is a common interference and likely to introduce meaningful biases, as illustrated with potassium analysis. Icterus, lipemia, salicylate, and iodide appear unlikely to cause clinically significant bias. Nitroprusside therapy introduced a slight rise in whole blood chloride concentrations that probably has minimal clinical significance.

Bovine mammary gland X chromosome inactivation

X chromosome inactivation (XCI) is a process by which 1 of the 2 copies of the X chromosomes present in female mammals is inactivated. The transcriptional silencing of one X chromosome achieves dosage compensation between XX females and XY males and ensures equal expression of X-linked genes in both sexes. Although all mammals use this form of dosage compensation, the complex mechanisms that regulate XCI vary between species, tissues, and development. These mechanisms include not only varying levels of inactivation, but also the nature of inactivation, which can range from being random in nature to driven by parent of origin. To date, no data describing XCI in calves or adult cattle have been reported and we are reliant on data from mice to infer potential mechanisms and timings for this process. In the context of dairy cattle breeding and genomic prediction, the implications of X chromosome inheritance and XCI in the mammary gland are particularly important where a relatively small number of bulls pass their single X chromosome on to all of their daughters. We describe here the use of RNA-seq, whole genome sequencing and Illumina BovineHD BeadChip (Illumina, San Diego, CA) genotypes to assess XCI in lactating mammary glands of dairy cattle. At a population level, maternally and paternally inherited copies of the X chromosome are expressed equally in the lactating mammary gland consistent with random inactivation of the X chromosome. However, average expression of the paternal chromosome ranged from 10 to 90% depending on the individual animal. These results suggest that either the mammary gland arises from 1 or 2 stem cells, or a nongenetic mechanism that skews XCI exists. Although a considerable amount of future work is required to fully understand XCI in cattle, the data reported here represent an initial step in ensuring that X chromosome variation is captured and used in an appropriate manner for future genomic selection.

Detection and assessment of copy number variation using PacBio long-read and Illumina sequencing in New Zealand dairy cattle

Single nucleotide polymorphisms have been the DNA variant of choice for genomic prediction, largely because of the ease of single nucleotide polymorphism genotype collection. In contrast, structural variants (SV), which include copy number variants (CNV), translocations, insertions, and inversions, have eluded easy detection and characterization, particularly in nonhuman species. However, evidence increasingly shows that SV not only contribute a substantial proportion of genetic variation but also have significant influence on phenotypes. Here we present the discovery of CNV in a prominent New Zealand dairy bull using long-read PacBio (Pacific Biosciences, Menlo Park, CA) sequencing technology and the Sniffles SV discovery tool (version 0.0.1; https://github.com/fritzsedlazeck/Sniffles). The CNV identified from long reads were compared with CNV discovered in the same bull from Illumina sequencing using CNVnator (read depth-based tool; Illumina Inc., San Diego, CA) as a means of validation. Subsequently, further validation was undertaken using whole-genome Illumina sequencing of 556 cattle representing the wider New Zealand dairy cattle population. Very limited overlap was observed in CNV discovered from the 2 sequencing platforms, in part because of the differences in size of CNV detected. Only a few CNV were therefore able to be validated using this approach. However, the ability to use CNVnator to genotype the 557 cattle for copy number across all regions identified as putative CNV allowed a genome-wide assessment of transmission level of copy number based on pedigree. The more highly transmissible a putative CNV region was observed to be, the more likely the distribution of copy number was multimodal across the 557 sequenced animals. Furthermore, visual assessment of highly transmissible CNV regions provided evidence supporting the presence of CNV across the sequenced animals. This transmission-based approach was able to confirm a subset of CNV that segregates in the New Zealand dairy cattle population. Genome-wide identification and validation of CNV is an important step toward their inclusion in genomic selection strategies.

Frequency and causes of lipemia interference of clinical chemistry laboratory tests

Objectives

The aims of this study were to identify the causes of severe lipemia in an academic medical center patient population and to determine the relationship between lipemia and hemolysis.

Design and methods

Retrospective study was done on the data from the core clinical laboratory at an academic medical center. Lipemic indices were available for all chemistry specimens analyzed over a 16-month period (n=552,029 specimens) and for serum/plasma triglycerides concentrations ordered for clinical purposes over a 16-year period (n=393,085 specimens). Analysis was performed on Roche Diagnostics cobas 8000 analyzers. Extensive chart review was done for all specimens with lipemic index greater than 500 (severely lipemic) and for all specimens with serum/plasma triglycerides greater than 2000 mg/dL. We also determined the relationship between lipemia and hemolysis.

Results

The most frequent suspected causes of very high lipemic index (>500) were found to be lipid-containing intravenous infusions (54.4% of total; fat emulsions for parenteral nutrition – 47%; propofol −7.4%) and diabetes mellitus (25% of total, mainly type 2). The most frequent suspected causes of very elevated serum/plasma triglycerides (>2000 mg/dL) was diabetes mellitus (64%, mainly type 2) and hyperlipidemia (16.9%). The frequency of hemolysis increased with increasing lipemic index.

Conclusions

Intravenous lipid infusions and type 2 diabetes were the most common causes of severe lipemia in this study at an academic medical center. Given that iatrogenic factors are the most common cause of severe lipemia, education and intervention may be helpful in reducing frequency of severe lipemia in patient specimens.

•

Intravenous lipids and type 2 diabetes were most common causes of severe lipemia.

•

The frequency of hemolysis increased with increasing lipemic index.

•

Diabetes type 2 was the most common cause of extreme hypertriglyceridemia.

•

Education and intervention may be helpful in reducing frequency of lipemia.

The prevalence of symptomatic pelvic floor disorders in women in Bangladesh

OBJECTIVE

To investigate the prevalence of, and risk factors for, pelvic floor disorders (PFDs) in women in Bangladesh.

METHODS

A nationally representative sample of 1590 Bangladeshi women, aged 30-59 years, was recruited using a multistage cluster sampling technique, between September 2013 and March 2014. Urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) were assessed using validated questionnaires. The weighted prevalence and the factors associated with each PFD were investigated using multivariable weighted logistic regression.

RESULTS

The weighted prevalence of UI was 23.7% (95% confidence interval (CI) 21.3-26.0%), FI 5.3% (95% CI 4.0-6.6%), POP 16.2% (95% CI 14.2-18.2%), and having at least one PFD 35.3% (95% CI 32.6-37.9%). Women were more likely to have at least one PFD if aged 40-49 years (adjusted odds ratio (AOR) 1.46, 95% CI 1.02-2.08; p = 0.040) or 50-59 years (AOR 2.39, 95% CI 1.59-3.58; p < 0.0001), compared with women aged 30-39 years. Having at least one PFD was positively associated with having three or more versus fewer children (AOR 1.61, 95% CI 1.14-2.27; p = 0.007), being in the middle (AOR 3.05, 95% CI 1.72-5.41; p < 0.0001), second lowest (AOR 2.49, 95% CI 1.39-4.47; p = 0.002) or lowest (AOR 3.13, 95% CI 1.68-5.86; p < 0.0001) wealth quintile compared with the highest, and self-reporting diabetes (AOR 2.55, 95% CI 1.54-4.23; p < 0.0001).

CONCLUSIONS

One-third of Bangladeshi women aged 30-59 years had at least one symptomatic PFD. Risk factors included greater age, higher parity, lower wealth status and self-reported diabetes. The diagnosis, treatment, and prevention of PFDs in Bangladesh need greater attention, as the prevalence of these disabling conditions is likely to increase with the aging of the population.

Implementation of Epic Beaker Clinical Pathology at an academic medical center

BACKGROUND

Epic Beaker Clinical Pathology (CP) is a relatively new laboratory information system (LIS) operating within the Epic suite of software applications. To date, there have not been any publications describing implementation of Beaker CP. In this report, we describe our experience in implementing Beaker CP version 2012 at a state academic medical center with a go-live of August 2014 and a subsequent upgrade to Beaker version 2014 in May 2015. The implementation of Beaker CP was concurrent with implementations of Epic modules for revenue cycle, patient scheduling, and patient registration.

METHODS

Our analysis covers approximately 3 years of time (2 years preimplementation of Beaker CP and roughly 1 year after) using data summarized from pre- and post-implementation meetings, debriefings, and the closure document for the project.

RESULTS

We summarize positive aspects of, and key factors leading to, a successful implementation of Beaker CP. The early inclusion of subject matter experts in the design and validation of Beaker workflows was very helpful. Since Beaker CP does not directly interface with laboratory instrumentation, the clinical laboratories spent extensive preimplementation effort establishing middleware interfaces. Immediate challenges postimplementation included bar code scanning and nursing adaptation to Beaker CP specimen collection. The most substantial changes in laboratory workflow occurred with microbiology orders. This posed a considerable challenge with microbiology orders from the operating rooms and required intensive interventions in the weeks following go-live. In postimplementation surveys, pathology staff, informatics staff, and end-users expressed satisfaction with the new LIS.

CONCLUSIONS

Beaker CP can serve as an effective LIS for an academic medical center. Careful planning and preparation aid the transition to this LIS.

Suspension of milking in dairy cows produces a transient increase in milk lactoferrin concentration and yield after resumption of milking

Lactoferrin is a multifunctional glycoprotein with a range of antimicrobial and immune-related properties that is found at >10-fold higher concentration in human milk (~1.7 g/L) relative to bovine milk (~0.15 g/L). Consumer demand is increasing for bovine lactoferrin through a wide range of nutritional and cosmetic consumer products. Increasing lactoferrin yield and concentration in bovine milk could assist in satisfying this increasing demand and may also help in increasing resistance to bovine mammary infection. Two experiments with cows in mid and late lactation were carried out to examine milking strategies to increase milk lactoferrin concentration and yield. Milking was suspended in cows normally milked twice daily, for periods of 2, 4, or 7d (mid lactation) or 2 or 4d (late lactation) after which cows were milked out and twice-daily milking resumed for 4d. In all groups, lactoferrin concentration was significantly increased during the remilking period, approaching concentrations similar to those found in human milk (~1 g/L). Lactoferrin yields were significantly higher in all treatment groups, although increasing the nonmilking period beyond 2d offered no advantage. Milk yield was lower initially after resumption of milking but recovered to preexperimental values by the fourth day of remilking in all groups, except the 4-d nonmilking group in late lactation. Milk somatic cell count was significantly elevated in all groups at the start of remilking but had substantially reduced by d 4 and reached a preexperimental level in the 2-d nonmilking group of mid-lactation cows. In summary, extended milking intervals can be used as a tool to produce a short-term increase in the concentration and yield of lactoferrin from bovine milk during established lactation, without any apparent long-term effects on milk yield and quality.

Lactation traits associated with short- and long-term once-daily milking performance in New Zealand crossbred dairy cattle

The main objectives of this study were to establish the relative value of milk yields under twice-daily milking (TDM) as a predictor of yield and yield loss under once-daily milking (ODM), and to understand the role of residual milk and udder storage capacity-related traits in regulating yield and yield loss during ODM. A Holstein-Friesian × Jersey crossbred herd was established over 2 seasons (years), as 2 individual cohorts on the same farm, managed on a pasture-based system over 4 lactations. Short-term (1-wk) ODM studies, with a starting total of 690 cows, were undertaken in mid- and late-lactation in lactation 2 and in mid-lactation in lactation 3 for each cohort. A 10-wk study of ODM performance began in mid-lactation in lactation 3, whereas lactation 4 was a full-lactation assessment of ODM. In the short-term studies, milk yield under ODM was well predicted (R(2)=0.7 to 0.8 in 5 of 6 studies) by the daily yield under TDM in the week before ODM. Yield loss (kg/d) increased with increasing milk yield and with increasing somatic cell count (SCC), although predictions were relatively poor (R(2)=0.09 to 0.30). Yield loss (%) decreased with increasing TDM yield in 3 of the 6 studies and was positively correlated with SCC during ODM. Nevertheless, ODM yield loss, in absolute or percentage terms, was a poorly repeatable trait in grazing cows. Part of the variation in yield loss percentage (30%) was positively associated with residual milk (%), measured pretrial, during measurement of functional udder capacity in lactation 3. Total production (kg of milk) over the full-lactation ODM study in lactation 4 was correlated with total production in the 10-wk trial in lactation 3 (r=0.72 and 0.63 for cohorts 1 and 2, respectively). Identifying the highest- and lowest-producing 10% of animals during the full lactation of ODM indicated that poor production was associated with high yields of residual milk (measured in lactation 3) and, conversely, high production was associated with low yields of residual milk, relative to the other 80% of animals. These same "high" and "low" production groups from lactation 4 had similar differences in performance in the earlier short-term studies and a larger or smaller percentage yield loss associated with the residual milk measurement. Breeding strategies for ODM may benefit, therefore, from greater emphasis on selecting for a low residual milk fraction to optimize milking performance. Nevertheless, the level of milk production under TDM is a strong phenotypic predictor of milk production under ODM.

Impact of add-on laboratory testing at an academic medical center: a five year retrospective study

Background

Clinical laboratories frequently receive orders to perform additional tests on existing specimens (‘add-ons’). Previous studies have examined add-on ordering patterns over short periods of time. The objective of this study was to analyze add-on ordering patterns over an extended time period. We also analyzed the impact of a robotic specimen archival/retrieval system on add-on testing procedure and manual effort.

Methods

In this retrospective study at an academic medical center, electronic health records from were searched to obtain all add-on orders that were placed in the time period of May 2, 2009 to December 31, 2014.

Results

During the time period of retrospective study, 880,359 add-on tests were ordered on 96,244 different patients. Add-on testing comprised 3.3 % of total test volumes. There were 443,411 unique ordering instances, leading to an average of 1.99 add-on tests per instance. Some patients had multiple episodes of add-on test orders at different points in time, leading to an average of 9.15 add-on tests per patient. The majority of add-on orders were for chemistry tests (78.8 % of total add-ons) with the next most frequent being hematology and coagulation tests (11.2 % of total add-ons). Inpatient orders accounted for 66.8 % of total add-on orders, while the emergency department and outpatient clinics had 14.8 % and 18.4 % of total add-on orders, respectively. The majority of add-ons were placed within 8 hours (87.3 %) and nearly all by 24 hours (96.8 %). Nearly 100 % of add-on orders within the emergency department were placed within 8 hours. The introduction of a robotic specimen archival/retrieval unit saved an average of 2.75 minutes of laboratory staff manual time per unique add-on order. This translates to 24.1 hours/day less manual effort in dealing with add-on orders.

Conclusion

Our study reflects the previous literature in showing that add-on orders significantly impact the workload of the clinical laboratory. The majority of add-on orders are clinical chemistry tests, and most add-on orders occur within 24 hours of original specimen collection. Robotic specimen archival/retrieval units can reduce manual effort in the clinical laboratory associated with add-on orders.

Targeted assessment of fracture risk in women at midlife

This study establishes a profile for women at midlife, referred for a dual energy X-ray absorptiometry (DXA), most likely to have osteoporosis, and from this, a pre-DXA screening tool has been developed. These findings inform much needed evidence-based guidelines for targeted and effective screening for osteoporosis and osteoporotic fracture prevention in women at midlife.

INTRODUCTION

There is no consensus as to whether women at midlife should undergo screening dual energy X-ray absorptiometry (DXA) to identify osteoporosis (T-score < -2.5).

METHODS

We investigated the prevalence of osteoporosis in women, aged 40-65 years, referred to 42 community-based Australian radiology centres, and identified the characteristics that best predict osteoporosis in women having a screening DXA.

RESULTS

One thousand four hundred and two women completed the study questionnaire and had DXA reports available. After excluding women with an established indication for a DXA (58 %), users of bone-specific medication (10.5 %) and cancer (7.6 %), 466 women were classified as having a screening DXA. Forty of these women had osteoporosis at the lumbar spine (n = 32, 6.9 %) or femoral neck (n = 17, 3.6 %). Three predictors of osteoporosis (postmenopausal, nonuse of hormonal therapy and body mass index) were identified and incorporated into the Monash Osteoporosis Risk Score for women at midlife (MORS). In the screened study population, the MORS had a sensitivity of 70 % and specificity of 66 %, with a positive predictive value of 16.2 % and negative predictive value of 95.9 % for osteoporosis.

CONCLUSIONS

Very few women referred for a screening DXA scan will be found to have osteoporosis. The MORS, a simple decision tool, would have identified 70 % of the women in our screening DXA study population and would have eliminated over 60 % of the screening DXA studies. Hence, use of the MORS may reduce unnecessary DXA scans and facilitate identification of the majority of cases of osteoporosis in women aged 40 to 65 years.

Intended follow up of women with breast cancer at low risk of recurrence and at least 5 years from diagnosis

BACKGROUND

Although there is evidence that minimal surveillance is compatible with an optimal outcome in women after early stage breast cancer, little is known of the surveillance that these women receive.

AIMS

To describe the intended clinical follow up and patterns of use of imaging modalities in low-risk breast cancer survivors who are at least 5 years from diagnosis.

METHODS

Participants in the Bupa Health Foundation Health and Wellbeing After Breast Cancer Study with stage 1 invasive breast cancer at diagnosis, who had survived free of recurrence or new primary breast cancer for at least 5 years, provided information for this analysis.

RESULTS

The most common choice of physician follow up was with one doctor only (54%). Within this group, the most frequent choice was a general practitioner (GP) (63%) followed by medical oncologist (23%). Thirty-five per cent of women said that they intended to consult two doctors and within this group, the most common combination was a GP and a medical oncologist (45%). This was despite two out of three women reporting being advised that there was no need to consult a medical oncologist. Over 90% of women reported having a mammogram with, or without, breast ultrasound in the previous 12 months. There was a low rate of use of other imaging tests in the absence of clear indications.

CONCLUSIONS

Minimising unnecessary medical consultations by women with breast cancer at low risk of recurrence 5 years from diagnosis will require education about the benefits of a minimal surveillance strategy.

Minimal-trauma fracture in women with breast cancer surviving for at least 5 years from diagnosis

SUMMARY

Minimal-trauma fracture is an important issue in breast cancer survivors, especially rib fracture. The likelihood of fracture is affected by menopausal status and a diagnosis of osteoporosis prior to breast cancer. Most women reported at least one assessment of bone mineral density.

INTRODUCTION

We have investigated the self-reported frequency and pattern of minimal-trauma fracture (MTF) in breast cancer (BC) survivors at least 5 years from diagnosis, along with the use of bone mineral density (BMD) assessment.

METHODS

This study was carried out within the Bupa Health Foundation Health and Wellbeing After Breast Cancer Study which is a questionnaire-based prospective cohort study of 1683 women diagnosed with their first invasive breast cancer between 2004 and 2006 and followed for at least 5 years.

RESULTS

One thousand two hundred and five women, who remained free of recurrence or new breast cancer, completed the fifth annual follow-up. One hundred sixty-four (13.6%) reported at least one MTF. Rib fracture was the most common (52 fractures in 46 women). Compared with women who remained pre-/peri-menopausal, either being postmenopausal at diagnosis (OR 3.53, 95% Confidence Interval (CI) 1.09-11.44, p=0.036) or changing from pre- to postmenopausal during follow-up (OR 3.97, 95% CI 1.21-13.10, p=0.023) was associated with a higher likelihood of fracture, as was having a diagnosis of osteoporosis at the time of diagnosis (OR 1.74, 95% CI 1.00-2.99, p=0.047). Most women (64.9%) reported at least one BMD assessment.

CONCLUSIONS

Overall MTF is a problem for breast cancer survivors, with rib fracture a particular issue for women in our study. Both pre-existing osteoporosis and being postmenopausal are risk factors for subsequent MTF in women treated for breast cancer. Clinicians need to be mindful of fracture prevention medication in these groups.

Vasomotor symptoms and urogenital atrophy in older women: a systematic review

OBJECTIVE

Our aim was to systematically review published articles for the prevalence of persistent estrogen depletion symptoms among women aged 65+ years.

METHODS

A systematic literature search of English-language publications was performed using MEDLINE, EMBASE, CINAHL, and PsycINFO. Twenty-three studies that included information on the prevalence of vasomotor and/or urogenital atrophy symptoms among older women (65 + years) met our inclusion criteria. Risk of bias of the included studies was assessed using a risk-of-bias tool explicitly designed for the systematic review of prevalence studies.

RESULTS

The available data suggest that vasomotor symptoms are experienced by a considerable proportion of older women, that symptoms of urogenital atrophy including urinary incontinence are widespread, and that women remain sexually active well into later life. A high degree of variability was observed for the prevalence of estrogen deficiency symptoms for women age 65+ years. Discrepancies in modes of recruitment, sampling procedures, time frames over which symptoms were assessed and use of different and non-validated assessment tools contributed to the inconsistencies across the published studies.

CONCLUSION

Larger and appropriately sampled studies, employing validated questionnaires, are still needed to establish the prevalence of persistent estrogen depletion symptoms in women aged 65+ years.

Association between urinary C-telopeptide fragments of type II collagen and knee structure in middle-aged women without clinical knee disease

OBJECTIVE

There is evidence for an association between levels of urinary C-telopeptide fragments of type II collagen (uCTX-II) and risk of knee osteoarthritis (OA). The aim of this cohort study was to examine the association between uCTX-II levels and knee cartilage and bone changes in middle-aged women without clinical knee disease.

DESIGN

140 women, aged 40-67 years, with no significant knee pain, knee injury or any forms of arthritis, underwent knee magnetic resonance imaging (MRI) at baseline and 2 years later. Cartilage volume, cartilage defects, tibial plateau bone area and bone marrow lesions (BMLs) were measured using validated methods. Baseline uCTX-II was measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

For every one unit (natural logarithm transformed) increase in baseline uCTX-II level, there was an increase in the prevalence of medial tibiofemoral cartilage defects (Odds ratio (OR) 4.36, 95% confidence interval (CI) 1.58-12.04), medial (80.2 mm(2), 95% CI 9.3-151.1) and lateral (86.0 mm(2), 95% CI 33.3-138.7) tibial plateau bone area, and the prevalence of lateral tibiofemoral BMLs (OR 10.62, 95% CI 1.82-61.85). Baseline uCTX-II levels were not significantly associated with baseline tibial cartilage volume or changes in knee cartilage volume or defects or bone area over 2 years, although there was a trend for the deterioration of medial tibiofemoral BMLs (P = 0.06).

CONCLUSION

In middle-aged women without clinical knee disease, higher uCTX-II levels were associated with early detrimental structural changes at the knee (cartilage defects, tibial bone expansion and BMLs) at baseline but not over 2 years. Further work will be needed to determine its sensitivity to change and whether it predicts disease progression over longer time periods.

Prevention of diseases after menopause

Women may expect to spend more than a third of their lives after menopause. Beginning in the sixth decade, many chronic diseases will begin to emerge, which will affect both the quality and quantity of a woman's life. Thus, the onset of menopause heralds an opportunity for prevention strategies to improve the quality of life and enhance longevity. Obesity, metabolic syndrome and diabetes, cardiovascular disease, osteoporosis and osteoarthritis, cognitive decline, dementia and depression, and cancer are the major diseases of concern. Prevention strategies at menopause have to begin with screening and careful assessment for risk factors, which should also include molecular and genetic diagnostics, as these become available. Identification of certain risks will then allow directed therapy. Evidence-based prevention for the diseases noted above include lifestyle management, cessation of smoking, curtailing excessive alcohol consumption, a healthy diet and moderate exercise, as well as mentally stimulating activities. Although the most recent publications from the follow-up studies of the Women's Health Initiative do not recommend menopause hormonal therapy as a prevention strategy, these conclusions may not be fully valid for midlife women, on the basis of the existing data. For healthy women aged 50-59 years, estrogen therapy decreases coronary heart disease and all-cause mortality; this interpretation is entirely consistent with results from other randomized, controlled trials and observational studies. Thus. as part of a comprehensive strategy to prevent chronic disease after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered as part of the armamentarium.

Autoverification in a core clinical chemistry laboratory at an academic medical center

Background:

Autoverification is a process of using computer-based rules to verify clinical laboratory test results without manual intervention. To date, there is little published data on the use of autoverification over the course of years in a clinical laboratory. We describe the evolution and application of autoverification in an academic medical center clinical chemistry core laboratory.

Subjects and Methods:

At the institution of the study, autoverification developed from rudimentary rules in the laboratory information system (LIS) to extensive and sophisticated rules mostly in middleware software. Rules incorporated decisions based on instrument error flags, interference indices, analytical measurement ranges (AMRs), delta checks, dilution protocols, results suggestive of compromised or contaminated specimens, and ‘absurd’ (physiologically improbable) values.

Results:

The autoverification rate for tests performed in the core clinical chemistry laboratory has increased over the course of 13 years from 40% to the current overall rate of 99.5%. A high percentage of critical values now autoverify. The highest rates of autoverification occurred with the most frequently ordered tests such as the basic metabolic panel (sodium, potassium, chloride, carbon dioxide, creatinine, blood urea nitrogen, calcium, glucose; 99.6%), albumin (99.8%), and alanine aminotransferase (99.7%). The lowest rates of autoverification occurred with some therapeutic drug levels (gentamicin, lithium, and methotrexate) and with serum free light chains (kappa/lambda), mostly due to need for offline dilution and manual filing of results. Rules also caught very rare occurrences such as plasma albumin exceeding total protein (usually indicative of an error such as short sample or bubble that evaded detection) and marked discrepancy between total bilirubin and the spectrophotometric icteric index (usually due to interference of the bilirubin assay by immunoglobulin (Ig) M monoclonal gammopathy).

Conclusions:

Our results suggest that a high rate of autoverification is possible with modern clinical chemistry analyzers. The ability to autoverify a high percentage of results increases productivity and allows clinical laboratory staff to focus attention on the small number of specimens and results that require manual review and investigation.

Residual feed intake of lactating Holstein-Friesian cows predicted from high-density genotypes and phenotyping of growing heifers

A genomic prediction for residual feed intake (RFI) developed in growing dairy heifers (RFIgro) was used to predict and test breeding values for RFI in lactating cows (RFIlac) from an independent, industry population. A selection of 3,359 cows, in their third or fourth lactation during the study, of above average genetic merit for milk production, and identified as at least 15/16ths Holstein-Friesian breed, were selected for genotyping from commercial dairy herds. Genotyping was carried out using the bovine SNP50 BeadChip (Illumina Inc., San Diego, CA) on DNA extracted from ear-punch tissue. After quality control criteria were applied, genotypes were imputed to the 624,930 single nucleotide polymorphisms used in the growth study. Using these data, genomically estimated breeding values (GEBV) for RFIgro were calculated in the selected cow population based on a genomic prediction for RFIgro estimated in an independent group of growing heifers. Cows were ranked by GEBV and the top and bottom 310 identified for possible purchase. Purchased cows (n=214) were relocated to research facilities and intake and body weight (BW) measurements were undertaken in 99 "high" and 98 "low" RFIgro animals in 4 consecutive groups [beginning at d 61 ± 1.0 standard error (SE), 91 ± 0.5 SE, 145 ± 1.3 SE, and 191 ± 1.5 SE d in milk, respectively] to measure RFI during lactation (RFIlac). Each group of ~50 cows (~25 high and ~25 low RFIgro) was in a feed intake facility for 35 d, fed pasture-alfalfa cubes ad libitum, milked twice daily, and weighed every 2 to 3 d. Milk composition was determined 3 times weekly. Body weight change and BW at trial mid-point were estimated by regression of pre- and posttrial BW measurements. Residual feed intake in lactating cows was estimated from a linear model including BW, BW change, and milk component yield (as MJ/d); RFIlac differed consistently between the high and low selection classes, with the overall means for RFIlac being +0.32 and -0.31 kg of dry matter (DM) per day for the high and low classes, respectively. Further, we found evidence of sire differences for RFIlac, with one sire, in particular, being highly represented in the low RFIgro class, having a mean RFIlac of -0.83 kg of DM per day in 47 daughters. In conclusion, genomic prediction of RFIgro based on RFI measured during growth will discriminate for RFIlac in an independent group of lactating cows.