Disposables used cumulatively in routine IVF procedures could display toxicity

STUDY QUESTION

Is there a cumulative toxicity of disposables used in IVF procedures?

SUMMARY ANSWER

A toxicity may be detected when consumables are used cumulatively, while no toxicity is detected when the same consumables are used and tested individually.

WHAT IS KNOWN ALREADY

Many components of items used in IVF laboratories may impair human embryonic development. Consequently, it is necessary to screen all reagents and materials which could be in contact with gametes and embryos. Toxicity tests, such as the mouse embryo assay and the human sperm motility assay (HSMA), are used by manufacturers as quality control tools to demonstrate the safety of their products. This evaluation is currently individually performed for each single consumable. However, during an IVF cycle, several devices are used sequentially, potentially creating a cumulative exposure to chemical contaminants, which could not be detected for individually tested consumables.

STUDY DESIGN, SIZE, DURATION

The objective of this observational study conducted from March 2021 to October 2022 was to evaluate with the HSMA methodology if there was a cumulative toxicity when several disposables are sequentially used. Fourteen categories of consumables currently used in routine IVF procedures were studied, which included devices used for sperm and oocyte collection (cups, condoms, and oocyte aspiration needles), manipulation (flasks, tubes, tips, pipettes, embryo transfer catheters, syringes, and gloves), culture (dishes), and storage (straws).

PARTICIPANTS/MATERIALS, SETTING, METHODS

After obtaining patient consent, the surplus semen assessed as having normal parameters according to the World Health Organization 2010 criteria were used to perform the HSMAs. First, each consumable was tested individually. Then, associations of three, four, and five consumables, previously validated as non-toxic when tested individually, were analyzed. HSMAs were conducted three times to ensure reproducibility, with a defined toxicity threshold of a sperm motility index (SMI) below 0.85 in at least two of three tests.

MAIN RESULTS AND THE ROLE OF CHANCE

Thirty-six references of disposables were first individually tested across 53 lots. Forty-nine (92%) demonstrated compliance. However, four (8%) devices revealed toxicity: one lot of 1 ml syringes, two lots of sperm cups, and one lot of 25 cm2 flasks. These four references were excluded from the IVF routine procedures. A total of 48 combinations of consumables were assessed, involving 41 lots from 32 references that were previously individually tested. Among the evaluated combinations, 17 out of 48 (35%) associations exhibited toxicity with a SMI below 0.85 for two of the three tests (n = 8) or all the three tests (n = 9). Notably, three out of 17 (18%) of the three-consumable associations, five out of 16 (31%) of the four-consumable associations, and nine out of 15 (60%) of the five-consumable associations were found not compliant. The toxicity did not originate from a single consumable, because only consumables that were individually pre-validated as non-toxic were included in the combinations, but the toxicity had a cumulative origin. The risk of cumulative toxicity increased with the number of consumables included in the association (Cochran-Mantel-Haenszel statistic, P = 0.013).

LIMITATIONS, REASONS FOR CAUTION

The high proportion of non-compliant combinations of disposables can be attributed directly to the extreme rigorous extraction conditions employed during the tests, which could deviate from the conditions encountered in routine clinical use. Also, the methodology employed in the HSMAs (e.g. toxicity extraction duration, sperm concentrations, and protein supplementation of the medium) can influence the sensitivity of the tests.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights the significance of performing toxicity testing on devices before introducing them into clinical practice. Disposables should be tested individually to detect immediate toxicities and also in combination. Our results advocate rationalizing the number of consumables used in each IVF procedure and re-evaluating the use of glass consumables.

STUDY FUNDING/COMPETING INTEREST(S)

This study received fundings from GCS Ramsay Santé pour l'Enseignement et la Recherche (Paris, France) and the Centre de Biologie Médicale BIOGROUP (Le Chesnay-Rocquencourt, France). The authors declare that they have no conflict of interest that could be perceived as prejudicing the impartiality of the reported research.

TRIAL REGISTRATION NUMBER

N/A.

Comparison of BP variability, cumulative BP, and BP trajectory for predicting cardiovascular events in the general population

OBJECTIVE

Systolic blood pressure variability (SBPV), cumulative systolic BP (cumSBP), and systolic blood pressure trajectory (trajSBP) are major indices describing characteristics of BP changes. The aim of this study was to compare their discrimination abilities for cardiovascular (CV) events.

METHODS

In 51698 subjects, associations were assessed using Cox regression in the overall cohort and Framingham risk score (FRS) stratified groups. Individuals with <10%, 10%-20%, and >20% 10-year CV risk were categorized into the low-, intermediate-, and high-risk group, respectively. Discrimination capabilities were evaluated using the area under curve (AUC), Harrell's C index, net reclassification index (NRI), and integrated discrimination index (IDI).

RESULTS

Within a mean follow-up of 6.83 ± 0.89 years, 2330 participants had CV events, and all three markers were significantly associated with CV events. TrajSBP provided the best additional discriminative value for CV events, with improvements of 1.54% in AUC%, 0.01 in Harrell's C, 37.52% in NRI%, and 0.59% in IDI%. CumSBP had good additional discriminative capability in the intermediate to high FRS groups, but the effect sizes were smaller than those of trajSBP. Although, SBPV improved the predictive capabilities in the low-to intermediate-risk groups, the effect sizes were much smaller than those of the other indices. Sensitivity analyses excluding patients who underwent antihypertensive therapy revealed similar patterns but higher effect sizes than in the overall population.

CONCLUSION

TrajSBP provides the best additional discrimination capabilities based on traditional risk profiles and may assist the risk stratification and individual prediction for future CV events.

Estradiol on trigger day: Irrelevant to live birth rates of fresh cycles but positively associated with cumulative live birth rates

OBJECTIVE

To assess the effects of estradiol (E2) on trigger day on cumulative live birth rates (CLBRs), and pregnancy outcomes after fresh and frozen-thawed embryo transfer (FET).

METHODS

This multicenter retrospective cohort study included 42 315 patients from five reproductive centers. Six subgroups were divided according to E2 on trigger day (<1000, 1000-2000, 2000-3000, 3000-4000, 4000-5000, >5000 pg/mL). Smooth curve fitting and nonlinear mixed-effects models were used.

RESULTS

When E2 was <5500 pg/mL, the CLBR increased by 10% for every 1000 pg/mL increase in E2. When E2 was between 5500 and 13 281 pg/mL, CLBR increased by 1.8% for every 1000 pg/mL increase in E2. When E2 was >13 281 pg/mL, CLBR decreased by 3% for every 1000 pg/mL increase in E2. From group E2 < 1000 to group E2 > 5000 pg/mL, pregnancy and live birth rates in fresh cycles were not related to E2. The live birth rate after FET was higher in the E2 ≥ 5000 pg/mL group than in the E2 < 1000 pg/mL group (odds ratio [OR] 4.03, and 95% confidence interval [CI] 3.74-4.35; adjusted OR 1.20, 95% CI 1.05-1.37).

CONCLUSION

CLBR is associated with E2 on trigger day in a segmented manner. Pregnancy and live birth rates in fresh cycles were not associated with E2. The live birth rate in FET cycles was highest when E2 ≥ 5000 pg/mL.

Cumulative Radiation Dose from Medical Imaging in Children with Congenital Heart Disease: A Systematic Review

Children with congenital heart disease are exposed to repeated medical imaging throughout their lifetime. Although the imaging contributes to their care and treatment, exposure to ionising radiation is known to increase one's lifetime attributable risk of malignancy. A systematic search of multiple databases was performed. Inclusion and exclusion criteria were applied to all relevant papers and seven were deemed acceptable for quality assessment and risk of bias assessment. The cumulative effective dose (CED) varied widely across the patient cohorts, ranging from 0.96 mSv to 53.5 mSv. However, it was evident across many of the included studies that a significant number of patients were exposed to a CED >20 mSv, the current annual occupational exposure limit. Many factors affected the dose which patients received, including age and clinical demographics. The imaging modality which contributed the most radiation dose to patients was cardiology interventional procedures. Paediatric patients with congenital heart disease are at an increased risk of receiving an elevated cumulative radiation dose across their lifetime. Further research should focus on identifying risk factors for receiving higher radiation doses, keeping track of doses, and dose optimisation where possible.

Aging and Economic Preferences: Cumulative meta-analyses of age differences in risk, time, social, and effort preferences

OBJECTIVES

Several theories predict changes in individuals' economic preferences across the life span. To test these theories and provide an historical overview of this literature, we conducted meta-analyses on age differences in risk, time, social, and effort preferences as assessed by behavioral measures.

METHODS

We conducted separate meta-analyses and cumulative meta-analyses on the association between age and risk, time, social, and effort preferences. We also conducted analyses of historical trends in sample sizes and citations patterns for each economic preference.

RESULTS

The meta-analyses identified overall no significant effects of age for risk (r = -0.02, 95%CI[-0.06, 0.02], n = 39,832), and effort preferences (r = 0.24, 95%CI[-0.05, 0.52], n = 571), but significant effects of age for time (r = -0.04, 95%CI[-0.07, -0.01], n = 115,496) and social preferences (r = 0.11, 95%CI[0.01, 0.21], n = 2,997), suggesting increased patience and altruism with age, respectively. Equivalence tests, that compare these effects to practically important ones (i.e., r = |.1|), however, suggest that all effects are of trivial significance. The analyses of temporal trends suggest that the magnitude of effects and sample sizes have not changed significantly over time, nor do they dramatically affect the extent that articles are cited.

DISCUSSION

Overall, our results contrast with theories of aging that propose general age effects for risk, and effort preferences, yet provide some but tenuous support for those suggesting age-related changes in time and social preferences. We discuss implications for theory development as well as future empirical work on economic preferences.

Estimated Impact of Low Isolate Numbers on the Reliability of Cumulative Antibiogram Data

Antibiograms are cumulative reports of antimicrobial susceptibility results that are used to guide the selection of empirical antibiotic therapy. Although Clinical and Laboratory Standards Institute (CLSI) guidelines recommend including only organisms that have at least 30 isolates in an antibiogram, previous studies demonstrated that adherence to this recommendation is highly variable. This paper aims to model the impact of small sample sizes on expected levels of error in cumulative antibiograms by comparing percent susceptibility results for random samples to those of the larger, entire data set. The results demonstrate relatively high error rates when utilizing low numbers of isolates in cumulative antibiograms, and provide a discussion point for considering the appropriate number of isolates that could be utilized, and the impact of increasing isolate numbers by including multiple years of data. IMPORTANCE Antibiograms are reports of local antimicrobial susceptibility patterns for common bacteria and yeast that are used to make empirical decisions for patient therapy and also to inform institution therapy guidelines. This study evaluates the impact of low isolate counts on the reliability of antibiograms, and suggests that more institutions should utilize multiple years of data to overcome this issue.

Pre-diagnostic predictors of mortality in patients with heart failure: The multi-ethnic study of atherosclerosis

Background

There are multiple predictive factors for cardiovascular (CV) mortality measured at, or after heart failure (HF) diagnosis. However, the predictive role of long-term exposure to these predictors prior to HF diagnosis is unknown.

Objectives

We aim to identify predictive factors of CV mortality in participants with HF, using cumulative exposure to risk factors before HF development.

Methods

Participants of Multi-Ethnic Study of Atherosclerosis (MESA) with incident HF were included. We used stepwise Akaike Information Criterion to select CV mortality predictors among clinical, biochemical, and imaging markers collected prior to HF. Using the AUC of B-spline-corrected curves, we estimated cumulative exposure to predictive factors from baseline to the last exam before HF. The prognostic performance for CV mortality after HF was evaluated using competing risk regression with non-CV mortality as the competing risk.

Results

Overall, 375 participants had new HF events (42.9% female, mean age: 74). Over an average follow-up of 4.7 years, there was no difference in the hazard of CV death for HF with reduced versus preserved ejection fraction (HR = 1.27, p = 0.23). The selected predictors of CV mortality in models with the least prediction error were age, cardiac arrest, myocardial infarction, and diabetes, QRS duration, HDL, cumulative exposure to total cholesterol and glucose, NT-proBNP, left ventricular mass, and statin use. The AUC of the models were 0.72 when including the latest exposure to predictive factors and 0.79 when including cumulative prior exposure to predictive factors (p = 0.20).

Conclusion

In HF patients, besides age and diagnosed diabetes or CVD, prior lipid profile, NT-proBNP, LV mass, and QRS duration available at the diagnosis time strongly predict CV mortality. Implementing cumulative exposure to cholesterol and glucose, instead of latest measures, improves predictive accuracy for HF mortality, though not reaching statistical significance.

Cumulative Metabolic and Epigenetic Effects of Paternal and/or Maternal Supplementation with Arachidonic Acid across Three Consecutive Generations in Mice

Apart from the known associations between arachidonic acid (AA), weight gain, and neurological and immune function, AA exposure leads to alterations in global and gene-specific DNA methylation (DNAm) and fatty acid (FA) content in human cultured cells. However, it is unknown as to whether the latter effects occur in vivo and are maintained over extended periods of time and across generations. To address this issue, we asked whether AA supplementation for three consecutive generations (prior to coitus in sires or in utero in dams) affected offspring growth phenotypes, in addition to liver DNAm and FA profiles in mice. Twelve-week-old BALB/c mice were exposed daily to AA dissolved in soybean oil (vehicle, VH), or VH only, for 10 days prior to mating or during the entire pregnancy (20 days). On average, 15 mice were supplemented per generation, followed by analysis of offspring body weight and liver traits (x average = 36 and 10 per generation, respectively). Body weight cumulatively increased in F2 and F3 offspring generations and positively correlated with milligrams of paternal or maternal offspring AA exposure. A concomitant increase in liver weight was observed. Notably, akin to AA-challenged cultured cells, global DNAm and cis-7-hexadecenoic acid (16:1n-9), an anti-inflammatory FA that is dependent on stearoyl-CoA desaturase 1 (SCD1) activity, increased with milligrams of AA exposure. In accordance, liver Scd1 promoter methylation decreased with milligrams of germline AA exposure and was negatively correlated with liver weight. Our results show that mice retain cellular memories of AA exposure across generations that could potentially be beneficial to the innate immune system.

Obstetric and perinatal outcomes of singleton pregnancies after blastocyst-stage embryo transfer compared with those after cleavage-stage embryo transfer: a systematic review and cumulative meta-analysis

BACKGROUND

Extended embryo culture to blastocyst stage is widely used in IVF and is the default strategy in most clinics. The last decade has witnessed a growing interest in obstetric-perinatal outcomes following blastocyst transfer. Recent studies have challenged the conclusions of systematic reviews that associate risks of preterm birth (PTB) and large for gestational age (LGA) babies with blastocyst transfer. A higher proportion of blastocysts is transferred as frozen-thawed embryos, which may also have added implications.

OBJECTIVE AND RATIONALE

The aim of this study was to conduct an updated systematic review of the obstetric-perinatal outcomes in singleton pregnancies following blastocyst-stage transfer compared to cleavage-stage transfer in IVF/ICSI cycles. Where deemed appropriate, data were combined in cumulative meta-analyses.

SEARCH METHODS

Data sources from Medline, EMBASE, CINAHL, Web of Science, the Cochrane Central Register of Clinical Trials and the International Clinical Trials Registry Platform (ICTRP) (1980-2020) were searched using combinations of relevant keywords. Searches had no language restrictions and were limited to human studies. Observational studies and randomized controlled trials comparing obstetric-perinatal outcomes between singleton pregnancies after blastocyst-stage transfer and those after cleavage-stage transfer in IVF/ICSI cycles were sought. Two independent reviewers extracted data in 2 × 2 tables and assessed the methodological quality of the relevant studies using the Critical Appraisal Skills Programme scoring. Cumulative meta-analyses were carried out with independent analysis of pregnancies after fresh and frozen embryo transfers, using the Comprehensive Meta-Analysis software. If provided by included studies, adjusted effect sizes were combined in a sensitivity analysis.

OUTCOMES

A total of 35 studies were included (n = 520 769 singleton pregnancies). Outcome data suggest singleton pregnancies following fresh blastocyst transfer were associated with higher risk of LGA (risk ratio (RR) 1.14; 95% CI 1.05-1.24) and very PTB (RR 1.17; 95% CI 1.08-1.26) compared to fresh cleavage-stage transfer. Singleton pregnancies following frozen blastocyst transfer were associated with higher risks of LGA (RR 1.17; 95% CI 1.08-1.27), PTB (RR 1.13; 95% CI 1.03-1.24) and caesarean section (RR 1.08; 95% CI 1.03-1.13) but lower risks of small for gestational age (RR 0.84, 95% CI 0.74-0.95) and perinatal mortality (RR 0.70; 95% CI 0.58-0.86). Increased risks of LGA and PTB after frozen blastocyst transfer persisted in the sensitivity analysis, which also showed a significantly increased risk of PTB after fresh blastocyst transfer. Cumulative meta-analyses revealed consistency in prevalence and magnitude of risks for a number of years. Data on other perinatal outcomes are still evolving.

WIDER IMPLICATIONS

While the available evidence is predominantly reassuring in the context of blastocyst-stage embryo transfer, observational data suggest that blastocyst transfer is associated with a higher risk of LGA. This holds true irrespective of fresh or frozen transfer. Meta-analysis of adjusted data showed an increased risk of PTB with fresh and frozen blastocyst transfer. However, the quality of available evidence ranges from low to very low. Although blastocyst-stage embryo transfer remains the default position in most centres, based on individual risk profile we may need to consider cleavage-stage embryo transfer in some to mitigate the risk of LGA/PTB.

Effect of long-term glucocorticoid therapy on cardiac functions in children with congenital adrenal hyperplasia

BACKGROUND

Glucocorticoids play an important role in cardiac physiology. Chronic exposure and higher doses may cause adverse effects on the myocardium, especially in young patients receiving long-term therapy.

OBJECTIVE

To assess cardiac function in children with congenital adrenal hyperplasia (CAH) and its relation to glucocorticoid dose and therapy duration.

METHODS

Forty-seven patients with CAH due to 21-hydroxylase deficiency were compared to 47 controls. Patients were subdivided according to treatment duration (Group A: less than 6 years, Group B: more than 6 years). Mean daily glucocorticoid and cumulative glucocorticoid doses were calculated. Echocardiography was performed for patients and controls to evaluate cardiac functions, chamber dimensions and tissue Doppler valvular status.

RESULTS

Compared to controls, patients had cardiac chamber hypertrophy reflected by higher M-mode dimensions. Patients had lower fractional shortening, defective ventricular relaxation, lower average mitral and tricuspid e´/a´ ratios (e´ early diastolic, a´ late diastolic) as well as s´ (systolic) velocities, higher average mitral E/e ratio and higher left ventricle TDI Tei index (P < .05). Group B had lower average mitral e´/a´ and tricuspid s´ velocities, and higher average mitral E/e ratio (P < .05). Cumulative glucocorticoid dose significantly correlated with different echocardiographic parameters.

CONCLUSION

Long-term glucocorticoid therapy even within the recommended therapeutic range adversely affects cardiac functions in children with 21-hydroxylase deficiency.

Association of Quantified Costal Cartilage Calcification and Long-Term Cumulative Blood Glucose Exposure: The Multi-Ethnic Study of Atherosclerosis

AIMS

Anecdotal reports have suggested increased soft tissue calcification in individuals with long-term exposures to high blood glucose. The association of costal cartilage calcification (CCC), a reliably quantifiable marker obtainable from non-contrast cardiac computed tomography (CT) with cumulative fasting blood glucose (FBG) exposure, is unknown. In this study, we aimed to determine the association between quantified CCC and cumulative glucose exposure using non-contrast coronary artery calcium (CAC) scoring computed tomography (CT) images in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

The volume of bilateral CCC was quantified in high-density pixels (threshold of Hounsfield Unit>180) using the CAC scoring CT images acquired in the 5^th MESA exam. Prior long-term cumulative exposure to FBG was calculated by area under the FBG-time curve over ten years before the time of the CT exam.

RESULTS

A total of 2,305 participants (mean age: 69, female/male: 1.3) were included in this study. The median CCC volume was lower in females than males (1158 mm³ [IQR: 1751] vs. 3054 mm³ [3851], p<0.001). In cross-sectional analysis, quantified CCC was associated with FBG (9% increase per SD) and HbA1c (7% increase per SD) at the CT exam only in female participants after adjustment for age, race, BMI, and glomerular filtration rate. Only in female participants, quantified CCC was also associated with prior cumulative FBG (3% increase per decile change). In the subgroup of females with zero CAC scores, the adjusted CCC was still associated with FBG (13% increase per SD) at the time of CT exam and with prior cumulative FBG exposure (4% increase per decile change) before the CT exam.

CONCLUSIONS

The CCC, a reliably quantified marker in non-contrast cardiac CT, is associated with 10-year cumulative FBG exposure only in female participants, even those with zero CAC.

Identification of a pesticide exposure based market basket suitable for cumulative dietary risk assessments and food monitoring programmes

Consideration of cumulative dietary risks is a requirement in the European legislation for setting maximum residue levels for pesticides. Current cumulative exposure assessment methodologies strongly rely on representative occurrence data from food monitoring programmes. This study provides a sensitivity analysis, utilising (i) European consumption data expressed as raw agricultural commodity (RAC) equivalents from 23 different countries as published by the European Food Safety Authority and (ii) all maximum residue levels established for pesticides under European Regulation (EC) No 396/2005. Based on two different degrees of conservatism, market baskets consisting of 16 or 41 RACs, respectively, were identified, covering the majority of the total chronic and acute daily exposure. The coverage of the exposure by these market baskets was tested by comparison of cumulative probabilistic exposure assessments for the German population using all food commodities and those using the reduced sets. It was demonstrated that ≥85% of the total chronic exposure is already covered by 16 RACs, while 41 RACs are required to reach a similarly satisfying coverage of the total acute exposure. Results from this study support resource efficient modelling of complex cumulative assessment scenarios and may help to improve the design of food monitoring programmes with respect to a more efficient assessment of potential consumer risks.

If Not Now, When? An Absence of Neurocognitive and Postural Stability Deficits in Collegiate Athletes with One or More Concussions

A history of concussion has been associated with decreased neurocognitive function and postural control. The purpose of our study was to compare neurocognitive function and postural control in collegiate athletes with and without varying histories of concussion. Collegiate athletes were divided into groups based on 0 (n = 129), 1 (n = 91), 2 (n = 52), and 3+ (n = 34) prior concussions. Participants in each group were carefully matched by sport, sex, height, weight, and age. Athletes were administered the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT™) and the Sensory Organization Test (SOT) as part of a standard of care pre-season assessment. Group ImPACT (Verbal and Visual Memory, Visual Motor Speed, and Reaction Time) and SOT (Equilibrium Score and Somatosensory, Visual, and Vestibular sensory ratios) outcome scores were compared using one-way analyses of variance (ANOVAs). Coefficients of variation (CVs) were also calculated for each outcome score and were compared using two-sample tests with 95% confidence intervals (CIs). Participants with and without a history of concussion were not significantly different for any ImPACT or SOT outcome score (p's > 0.10). Groups (0, 1, 2, and 3+ previous concussions) were not different from each other for any ImPACT or SOT outcome score (p's ≥ 0.11). Likewise, the CVs associated with each ImPACT and SOT outcome score did not vary significantly between outcome scores for any group comparison (p ≥ 0.09). Our findings suggest that a history of one or more concussions does not influence neurocognitive performance or postural stability in collegiate athletes at their pre-season baseline assessment.

Accumulation Bias in meta-analysis: the need to consider time in error control

Studies accumulate over time and meta-analyses are mainly retrospective. These two characteristics introduce dependencies between the analysis time, at which a series of studies is up for meta-analysis, and results within the series. Dependencies introduce bias —Accumulation Bias— and invalidate the sampling distribution assumed for p-value tests, thus inflating type-I errors. But dependencies are also inevitable, since for science to accumulate efficiently, new research needs to be informed by past results. Here, we investigate various ways in which time influences error control in meta-analysis testing. We introduce an Accumulation Bias Framework that allows us to model a wide variety of practically occurring dependencies including study series accumulation, meta-analysis timing, and approaches to multiple testing in living systematic reviews. The strength of this framework is that it shows how all dependencies affect p-value-based tests in a similar manner. This leads to two main conclusions. First, Accumulation Bias is inevitable, and even if it can be approximated and accounted for, no valid p-value tests can be constructed. Second, tests based on likelihood ratios withstand Accumulation Bias: they provide bounds on error probabilities that remain valid despite the bias. We leave the reader with a choice between two proposals to consider time in error control: either treat individual (primary) studies and meta-analyses as two separate worlds — each with their own timing — or integrate individual studies in the meta-analysis world. Taking up likelihood ratios in either approach allows for valid tests that relate well to the accumulating nature of scientific knowledge. Likelihood ratios can be interpreted as betting profits, earned in previous studies and invested in new ones, while the meta-analyst is allowed to cash out at any time and advice against future studies.

Evaluation of Maculopathy in Patients Using Hydroxychloroquine

Objectives:

To determine length of hydroxychloroquine use and cumulative dose and evaluate the ocular effects by 10-2 central visual field test, microperimetry (MP), color fundus photography, optical coherence tomography (OCT), and fundus autofluorescence (FAF) in hydroxychloroquine users.

Materials and Methods:

Patients who used hydroxychloroquine continuously for at least 2 years for various connective tissue diseases were included in the study. A total of 300 eyes of 150 patients aged 19-78 years who were followed due to risk of developing hydroxychloroquine maculopathy in the İstanbul University İstanbul Faculty of Medicine Ophthalmology Department between the years 1995-2017 were evaluated. Best corrected visual acuity (BCVA), biomicroscopic, and fundoscopic examination were performed at all visits. MP, FAF, OCT, fundus photography, and central 10-2 visual field examinations were performed 3 times at 6-month intervals.

Results:

The mean age of patients was 48.9±10.8 years; 141 (94%) patients were female and 9 (6%) were male. The mean duration of hydroxychloroquine use was 10.5±6.4 (2-30) years. Fifty-six patients had been using the drug for 5 years or less. The mean cumulative drug dose was 754.7±447.2 (146-1825) g. Mean BCVA was 0.02±0.08 LogMAR at all follow-up visits (p=0.999). Mean MP values at the first, second, and third examinations were 14.07±3.24 dB, 14.18±3.35 dB, and 14.54±2.79 dB, respectively (p>0.05). Mean central macular thickness was 221.9±19.8 μm at initial examination, 221.8±19.9 μm at the second visit, and 221.8±19.8 μm at the final visit (p=0.113). There was a weak negative correlation between age and MP values at all three visits (visit 1: p=0.003, r=-0.170; visit 2: p=0.001, r=-0.185, visit 3: p=0.011, r=-0.146). There was statistically significant relationship between MP values and hydroxychloroquine length of use and cumulative dose (p=0.027 and p=0.049, respectively). Duration of use was not associated with changes in 10/2 visual field (p=0.124). There were significant relationships between alterations in FAF and hydroxychloroquine length of use and cumulative dose (p=0.027 and p=0.049, respectively).

Conclusion:

FAF alterations were significantly associated with duration of hydroxychloroquine use and cumulative dose. As objective methods are more reliable, examinations such as FAF can be recommended as auxiliary methods in the follow-up and early detection of toxic maculopathy.

Cumulative effects of the Gulf oil spill and other disasters on mental health among reproductive-aged women: The Gulf Resilience on Women's Health study

OBJECTIVE

To test whether effects of multiple (up to 5) disasters on mental health responses were cumulative (additive effects), or whether an earlier disaster produced sensitization (higher) or habituation (lower) responses to a later one.

METHOD

The Gulf Resilience on Women's Health study interviewed 1,366 southern Louisiana women regarding their exposure to Hurricanes Katrina, Rita, Gustav, and Ike and the Gulf oil spill (measured several ways), and administered validated measures of symptoms of depression and posttraumatic stress disorder (PTSD). Multiple linear and logistic regression with disaster exposures entered singly, combined, and as an interaction were used to model mental health.

RESULTS

Both exposure to the oil spill and hurricane disaster were associated with likely depression and PTSD, consistent with a cumulative model, but we did not find statistical interactions that would suggest sensitization or habituation. When results were examined with continuous symptom measures of depression and PTSD, they were similar, with the exception that exposure to the oil spill and experiencing illness or injury because of the hurricane disaster showed a significant interaction (p < .05) in a manner consistent with a sensitization effect when predicting PTSD symptoms. The results of this study point mainly to a cumulative risk for the mental health effects of multiple disasters, although some indication of sensitization occurred among those with particularly severe experiences. There was no evidence for habituation.

CONCLUSIONS

These findings may guide efforts to assist those in regions experiencing multiple disasters that occur in close sequence. (PsycINFO Database Record

Modeling Cumulative Biological Phenomena with Suppes-Bayes Causal Networks

Several diseases related to cell proliferation are characterized by the accumulation of somatic DNA changes, with respect to wild-type conditions. Cancer and HIV are 2 common examples of such diseases, where the mutational load in the cancerous/viral population increases over time. In these cases, selective pressures are often observed along with competition, co-operation, and parasitism among distinct cellular clones. Recently, we presented a mathematical framework to model these phenomena, based on a combination of Bayesian inference and Suppes’ theory of probabilistic causation, depicted in graphical structures dubbed Suppes-Bayes Causal Networks (SBCNs). The SBCNs are generative probabilistic graphical models that recapitulate the potential ordering of accumulation of such DNA changes during the progression of the disease. Such models can be inferred from data by exploiting likelihood-based model selection strategies with regularization. In this article, we discuss the theoretical foundations of our approach and we investigate in depth the influence on the model selection task of (1) the poset based on Suppes’ theory and (2) different regularization strategies. Furthermore, we provide an example of application of our framework to HIV genetic data highlighting the valuable insights provided by the inferred SBCN

Investigating Effects of Sex Differences and Prior Concussions on Symptom Reporting and Cognition Among Adolescent Soccer Players

BACKGROUND

There has been increasing concern regarding the possible effect of multiple concussions on the developing brain, especially for adolescent females. Hypothesis/Purpose: The objectives were to determine if there are differences in cognitive functioning, symptom reporting, and/or sex effects from prior concussions. In a very large sample of youth soccer players, it was hypothesized that (1) there would be no differences in cognitive test performance between those with and without prior concussions, (2) baseline preseason symptoms would be better predicted by noninjury factors than concussion history, and (3) males and females with prior concussions would not have differences in cognition or symptoms.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Participants included 9314 youth soccer players (mean = 14.8 years, SD = 1.2) who completed preseason baseline cognitive testing, symptom reporting, and a health/injury history questionnaire from the ImPACT battery (Immediate Post-concussion Assessment and Cognitive Testing). On the basis of injury history, athletes were grouped by number of prior concussions: 0 (boys, n = 4012; girls, n = 3963), 1 (boys, n = 527; girls, n = 457), 2 (boys, n = 130; girls, n = 97), or ≥3 (boys, n = 73; girls, n = 55). The primary measures were the 4 primary cognitive scores and the total symptom ratings from ImPACT. Primary outcomes were assessed across injury groups, controlling for age, sex, learning disability, attention-deficit/hyperactivity disorder (ADHD), treatment for headaches/migraines, substance abuse, and mental health problems.

RESULTS

Cognitive test performance was not associated with concussion history but was associated with sex, age, learning disability, ADHD, and prior mental health problems. Greater symptom reporting was more strongly associated with psychiatric problems, older age, learning disability, substance abuse, headaches, being female, and ADHD than with a history of multiple concussions. Boys and girls did not differ on cognitive scores or symptom reporting based on a history of concussion.

CONCLUSION

In this very large sample of youth soccer players with prior concussion, there was no evidence of negative effects on cognition, very weak evidence of negative effects on symptom reporting, and no evidence of sex × concussion differences in cognition or symptom reporting.

Vulnerabilities to Health Disparities and Statin Use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study

Background

Statins may be underutilized in certain vulnerable populations, but the effect of cumulative vulnerabilities within 1 individual is not well described. We sought to determine the likelihood of receiving statins with an increasing number of vulnerabilities in an individual, after controlling for factors known to influence health services utilization.

Methods and Results

We identified 18 216 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study who had a statin indication or who were taking statins, as verified by pill bottle review. Statin use was assessed with respect to 5 major vulnerability domains alone and in combination: older age, black race, female sex, high area‐level poverty, and lack of health insurance. The study included 5286 white men, 4180 black men, 2791 white women, and 4194 black women; 5.6% of the sample had no vulnerabilities, 20.6% had 1 vulnerability, 29.2% had 2 vulnerabilities, 27.3% had 3 vulnerabilities, and 17.3% had 4 or 5 vulnerabilities. All race–sex groups were less likely than white men to use statins; prevalence of use was 0.80 in black women with reference to white men (P<0.0001). In both unadjusted and adjusted models, as the number of vulnerabilities increased, statin use steadily decreased. After adjusting for factors that influence health services utilization, compared with those without any vulnerabilities, statin use prevalence was 0.91, 0.83, 0.74 and 0.68 (P<0.0001) in those with 1, 2, 3, and 4 or 5 vulnerabilities, respectively.

Conclusions

Participants with more simultaneously occurring vulnerabilities experienced the greatest disparities in statin use. Black women and those without health insurance were at particularly high risk of underutilization.

Cumulative Risk Assessment in the Lorraine Region: A Framework to Characterize Environmental Health Inequalities

The study explores spatial data processing methods and the associated impact on the characterization and quantification of a combined health risk indicator at a regional scale and at fine resolution. To illustrate the methodology of combining multiple publicly available data sources, we present a case study of the Lorraine region (France), where regional stakeholders were involved in the global procedures for data collection and organization. Different indicators are developed by combining technical approaches for assessing and characterizing human health exposure to chemical substances (in soil, air and water) and noise risk factors. The results permit identification of pollutant sources, determinants of exposure, and potential hotspot areas. A test of the model’s assumptions to changes in sub-indicator spatial distribution showed the impact of data transformation on identifying more impacted areas. Cumulative risk assessment permits the combination of quantitative and qualitative evaluation of health risks by including stakeholders in the decision process, helping to define a subjective conceptual analysis framework or assumptions when uncertainties or knowledge gaps operate.

Antibiograms in resource limited settings: Are stratified antibiograms better?

Background Antibiograms often act as a reference guide for empirical selection of antibiotics. Hospital-wide antibiograms constructed on the basis of cumulative antimicrobial susceptibility data from diverse patient groups can often be misleading. In order to show the significance of age- and location-stratified antibiograms, this study compared hospital-wide antibiograms with stratified antibiograms for the clinical isolates of Pseudomonas aeruginosa. Methods Stratified antibiograms were created on the basis of patient age (<18 years, 18-50 years, >50 years) and location (inpatient or outpatient) using all 2011, 2012 and 2013 clinical isolates of P. aeruginosa isolates. Susceptibility rates were compared among cumulative and stratified antibiograms using non-parametric inferential statistics. Results The hospital-wide antibiogram under-estimated susceptibility rates in adult patients isolates (age group = 18-50 years) and over-estimated susceptibility rates in isolates from the paediatric patients and elderly. Paediatric isolates were found to be less susceptible to amikacin and imipenem, whereas isolates from elderly patients >50 years were less susceptible to ciprofloxacin. Statistically significant difference was seen in the susceptibility rates of OPD and IPD isolates of P. aeruginosa in the case of the paediatric age group. Susceptibility rates for all drugs were lower for isolates from inpatients than from outpatients. Conclusion Age and location associated differences in susceptibility rates have the potential to influence empirical antibiotic selection, which was shown in stratified antibiograms of P. aeruginosa that is obscured by hospital-wide antibiograms.

Cumulative radiation exposure estimates of hospitalized patients from radiological imaging

PURPOSE

To examine the use of inpatient diagnostic imaging and image-guided procedures to estimate cumulative radiation exposure, radiation exposure based on imaging modality, and compare estimated doses based on patient demographics including age, gender, and diagnoses.

METHODS

Two hundred consecutive hospitalized adult patients who underwent diagnostic imaging studies at 2 large, affiliated hospitals were identified, and every study in each patient's electronic record that took place during a single hospitalization was reviewed. Dose estimates were calculated for each CT, fluoroscopy, nuclear medicine, plain film, and interventional radiology study or procedure based on reported dose length product, published reference values, and conversion factors. Medical records were reviewed to determine patient gender, age, diagnoses, length of stay, admitting service, and time in an intensive care unit (ICU).

RESULTS

Two hundred inpatients (46.5% male; mean age, 60.4 years) underwent 2,751 imaging studies (79.3% radiographs, 9.7% CT, 6.1% ultrasound, 2.5% interventional radiology, 2.2% MRI, 0.4% nuclear medicine). The mean dose estimate per patient was 14.8 milliSieverts (mSv) and the range was 0 mSv to 130.5 mSv. Mean cumulative dose estimates were significantly higher for patients whose hospitalizations included time in an ICU (17.9 mSv versus 11.3 mSv [P = .01]). CT examinations accounted for 82.1% of the total radiation dose estimate. Eleven patients (5.5%) received radiation dose estimates ≥ 50 mSv, including 2 ≥ 100 mSv.

CONCLUSIONS

Of imaged inpatients, 62% underwent at least 1 CT and the majority (82.1%) of inpatient radiation exposure was attributable to CT examinations. Mean dose estimate was 14.8 mSv per patient; 5.5% of patients experienced estimated doses ≥ 50 mSv.

Effects of cumulative trauma load on perceptions of health, blood pressure, and resting heart rate in urban African American youth

PURPOSE

This study examined relationships between cumulative trauma (CT) and urban African American (AA) adolescents' blood pressure (BP), heart rate (HR), and perceptions of health.

DESIGN AND METHOD

A correlational design using secondary data analysis studied effects of CT, health outcomes, and perceptions of health. Participants were 175 urban AA youth (11-16 years) who completed structured surveys and physiological measures of HR and BP before and after exercise.

RESULTS

AA youth were experiencing high levels of CT. Negative correlations were obtained between AA females' perceptions of their health and systolic BP with levels of trauma. No gender differences were found in HR or BP.

PRACTICE IMPLICATIONS

AA females with high CT may perceive themselves as less healthy and can be at risk for health problems.

Determining the maximum cumulative ratios for mixtures observed in ground water wells used as drinking water supplies in the United States

The maximum cumulative ratio (MCR) developed in previous work is a tool to evaluate the need to perform cumulative risk assessments. MCR is the ratio of the cumulative exposures to multiple chemicals to the maximum exposure from one of the chemicals when exposures are described using a common metric. This tool is used to evaluate mixtures of chemicals measured in samples of untreated ground water as source for drinking water systems in the United States. The mixtures of chemicals in this dataset differ from those examined in our previous work both in terms of the predicted toxicity and compounds measured. Despite these differences, MCR values in this study follow patterns similar to those seen earlier. MCR values for the mixtures have a mean (range) of 2.2 (1.03–5.4) that is much smaller than the mean (range) of 16 (5–34) in the mixtures in previous study. The MCR values of the mixtures decline as Hazard Index (HI) values increase. MCR values for mixtures with larger HI values are not affected by possible contributions from chemicals that may occur at levels below the detection limits. This work provides a second example of use of the MCR tool in the evaluation of mixtures that occur in the environment.

Maximum cumulative ratio (MCR) as a tool for assessing the value of performing a cumulative risk assessment

Due to the vast number of possible combinations of chemicals to which individuals are exposed and the resource-intensive nature of cumulative risk assessments, there is a need to determine when cumulative assessments are most required. This paper proposes the use of the maximum cumulative ratio (MCR) as a tool for this evaluation. MCR is the ratio of the cumulative toxicity received by an individual from exposure to multiple chemical stressors to the largest toxicity from a single chemical stressor. The MCR is a quantitative measure of the difference in an individual’s toxicity estimated using a chemical-by-chemical approach and using an additive model of toxicity. As such, it provides a conservative estimate of the degree to which individuals’ toxicities could be underestimated by not performing a cumulative risk assessment. In an example application, MCR is shown to be applicable to the evaluation of cumulative exposures involving up to 81 compounds and to provide key insights into the cumulative effects posed by exposures to multiple chemicals. In this example, MCR values suggest that individuals exposed to combinations of chemicals with the largest Hazard Indices were dominated by the contributions of one or two compounds.

BMI Trajectories During the Transition to Older Adulthood: Persistent, Widening, or Diminishing Disparities by Ethnicity and Education?

Previous research has produced inconsistent results on whether education and ethnic disparities in body mass index (BMI) persist, widen, or diminish over time. The authors investigate how education and ethnicity, independently and conditionally, influence BMI trajectories during the transition to older adulthood. Employing random coefficient modeling, the authors analyzed eight biennial waves of data (1992-2006) from the Health and Retirement Study, a nationally representative longitudinal study of individuals born between 1931 and 1941. After adjusting for health behaviors and health status, education and ethnic disparities in BMI persisted for most groups, but narrowed between high-educated White men and both low-educated Hispanic men and high-educated Black men. As such, the findings generally support the persistent inequality interpretation. Therefore, even though interventions targeted at earlier points in the life course may be effective in reducing BMI disparities in later life, social and health policies directed at reducing obesity among older adults is also warranted.

Prostate cancer risk alleles significantly improve disease detection and are associated with aggressive features in patients with a "normal" prostate specific antigen and digital rectal examination

BACKGROUND

Several reports suggest that a combination of risk alleles may be associated with prostate cancer (CaP) risk and tumor features. However, their ability to detect CaP and tumor characteristics in patients with a "normal" PSA (<4 ng/ml) and non-suspicious digital rectal examination (DRE) remains to be determined.

METHODS

We examined 203 men of European ancestry with clinical stage T1c CaP diagnosed at a "normal" PSA and 611 healthy volunteer controls. The genotypes for 17 different risk alleles were compared between CaP cases and controls. Additional analyses were used to compare the pathologic features between carriers and non-carriers (defined using best-fit genetic model) of these variants.

RESULTS

All risk alleles were present at an increased frequency in cases with "normal" PSA values and DRE compared to controls. Amongst CaP patients, carriers of an increasing number of genetic risk factors (i.e., alleles and positive family history) were at a significantly increased risk of CaP (P-trend <0.001). Specifically, men with >10 genetic risk factors had an 11.2-fold risk (95% CI 4.3-29.2) of having the disease compared to men with ≤5 variants. There also was a higher frequency of many the variants amongst men with adverse pathologic features.

CONCLUSIONS

A substantial proportion of biopsy-detectable CaP occurs in men with "normal" PSA levels and negative DRE. In this population, CaP risk alleles and family history are significantly associated with CaP risk and may help predict aggressive disease. Future studies are warranted to determine the utility of incorporating these variants into CaP screening programs.

The EPA's human exposure research program for assessing cumulative risk in communities

Communities are faced with challenges in identifying and prioritizing environmental issues, taking actions to reduce their exposures, and determining their effectiveness for reducing human health risks. Additional challenges include determining what scientific tools are available and most relevant, and understanding how to use those tools; given these barriers, community groups tend to rely more on risk perception than science. The U.S. Environmental Protection Agency's Office of Research and Development, National Exposure Research Laboratory (NERL) and collaborators are developing and applying tools (models, data, methods) for enhancing cumulative risk assessments. The NERL's "Cumulative Communities Research Program" focuses on key science questions: (1) How to systematically identify and prioritize key chemical stressors within a given community?; (2) How to develop estimates of exposure to multiple stressors for individuals in epidemiologic studies?; and (3) What tools can be used to assess community-level distributions of exposures for the development and evaluation of the effectiveness of risk reduction strategies? This paper provides community partners and scientific researchers with an understanding of the NERL research program and other efforts to address cumulative community risks; and key research needs and opportunities. Some initial findings include the following: (1) Many useful tools exist for components of risk assessment, but need to be developed collaboratively with end users and made more comprehensive and user-friendly for practical application; (2) Tools for quantifying cumulative risks and impact of community risk reduction activities are also needed; (3) More data are needed to assess community- and individual-level exposures, and to link exposure-related information with health effects; and (4) Additional research is needed to incorporate risk-modifying factors ("non-chemical stressors") into cumulative risk assessments. The products of this research program will advance the science for cumulative risk assessments and empower communities with information so that they can make informed, cost-effective decisions to improve public health.

Evidence for dose-additive effects of pyrethroids on motor activity in rats

BACKGROUND

Pyrethroids are neurotoxic insecticides used in a variety of indoor and outdoor applications. Previous research characterized the acute dose-effect functions for 11 pyrethroids administered orally in corn oil (1 mL/kg) based on assessment of motor activity.

OBJECTIVES

We used a mixture of these 11 pyrethroids and the same testing paradigm used in single-compound assays to test the hypothesis that cumulative neurotoxic effects of pyrethroid mixtures can be predicted using the default dose-addition theory.

METHODS

Mixing ratios of the 11 pyrethroids in the tested mixture were based on the ED30 (effective dose that produces a 30% decrease in response) of the individual chemical (i.e., the mixture comprised equipotent amounts of each pyrethroid). The highest concentration of each individual chemical in the mixture was less than the threshold for inducing behavioral effects. Adult male rats received acute oral exposure to corn oil (control) or dilutions of the stock mixture solution. The mixture of 11 pyrethroids was administered either simultaneously (2 hr before testing) or after a sequence based on times of peak effect for the individual chemicals (4, 2, and 1 hr before testing). A threshold additivity model was fit to the single-chemical data to predict the theoretical dose-effect relationship for the mixture under the assumption of dose additivity.

RESULTS

When subthreshold doses of individual chemicals were combined in the mixtures, we found significant dose-related decreases in motor activity. Further, we found no departure from the predicted dose-additive curve regardless of the mixture dosing protocol used.

CONCLUSION

In this article we present the first in vivo evidence on pyrethroid cumulative effects supporting the default assumption of dose addition.

Preliminary validation of angle-independent myocardial elastography using MR tagging in a clinical setting

Myocardial elastography (ME), a radio-frequency (RF) based speckle tracking technique, was employed in order to image the entire two-dimensional (2D) transmural deformation field in full echocardiographic views and was validated against tagged magnetic resonance imaging (tMRI) in normal as well as reperfused (i.e., treated myocardial infarction [MI]) human left ventricles. RF ultrasound and tMRI frames were acquired at the papillary muscle level in 2D short-axis (SA) views at the frame rates of 136 (fps; real-time) and 33 fps (electrocardiogram [ECG]-gated), respectively. In ME, in-plane, 2D (lateral and axial) incremental displacements were iteratively estimated using one-dimensional (1D) cross-correlation and recorrelation techniques in a 2D search with a 1D matching kernel. In tMRI, cardiac motion was estimated by a template-matching algorithm on a 2D grid-shaped mesh. In both ME and tMRI, cumulative 2D displacements were obtained and then used to estimate 2D Lagrangian finite systolic strains, from which polar (i.e., radial and circumferential) strains, namely angle-independent measures, were further obtained through coordinate transformation. Principal strains, which are angle-independent and less centroid-dependent than polar strains, were also computed and imaged based on the 2D finite strains using methodology previously established. Both qualitatively and quantitatively, angle-independent ME is shown to be capable of (1) estimating myocardial deformation in good agreement with tMRI estimates in a clinical setting and of (2) differentiating abnormal from normal myocardium in a full left-ventricular view. The principal strains were concluded to be a potential diagnostic measure for detection of cardiac disease with reduced centroid dependence.