Does the environment affect menopause? A review of the effects of endocrine disrupting chemicals on menopause

Endocrine disrupting chemicals are widely distributed in our environment. Humans are exposed to these compounds not only through their occupations, but also through dietary consumption and exposure to contaminated water, personal care products and textiles. Chemicals that are persistent in the body and in our environment include dioxins and polychlorinated biphenyls. Non-persistent chemicals including bisphenol A, phthalates and parabens are equally as important because they are ubiquitous in our environment. Heavy metals, including lead and cadmium, can also have endocrine disrupting properties. Although difficult to study due to their variety of sources of exposures and mechanisms of action, these chemicals have been associated with early menopause, increased frequency of vasomotor symptoms, altered steroid hormone levels and markers of diminished ovarian reserve. Understanding the impacts of these exposures is important given the potential for epigenetic modification, which can alter gene function and result in multi-generational effects. This review summarizes findings in humans and animals or cell-based models from the past decade of research. Continued research is needed to assess the effects of mixtures of chemicals, chronic exposures and new compounds that are continuously being developed as replacements for toxic chemicals that are being phased out.

Telehealth and Public Health Practice in the United States-Before, During, and After the COVID-19 Pandemic

Telehealth is the use of electronic information and telecommunication technologies to provide care when the patient and the provider are not in the same room at the same time. Telehealth accounted for less than 1% of all Medicare Fee-for-Service outpatient visits in the United States in 2019 but grew to account for 46% of all visits in April 2020. Changes in reimbursement and licensure policies during the COVID-19 pandemic appeared to greatly facilitate this increased use. Telehealth will continue to account for a substantial portion of care provided in the United States and globally. A better understanding of telehealth approaches and their evidence base by public health practitioners may help improve their ability to collaborate with health care organizations to improve population health. The article summarizes the Centers for Disease Control and Prevention's (CDC's) approach to understanding the evidence base for telehealth in public health practice, possible applications for telehealth in public health practice, and CDC's use of telehealth to improve population health.

Preventing Suicidal Behavior Among American Indian and Alaska Native Adolescents and Young Adults

From 2009 to 2018, overall suicide rates in the United States increased by 20.3% and increased by 43.5% among non-Hispanic American Indian and Alaska Native (AI/AN) communities. Combining years 2009 through 2018, suicide rates per 100 000 population among non-Hispanic AI/AN adolescents and young adults aged 15 to 34 years were 2 to 4 times higher than those of adolescents and young adults of other races and ethnicities. An estimated 14% to 27% of non-Hispanic AI/AN adolescents attempted suicide during that time. The elevated rates of suicidal behavior among non-Hispanic AI/AN adolescents and young adults reflect inequities in the conditions that create health. In this topical review, we describe school-based educational efforts that are driven by local AI/AN communities, such as the American Indian Life Skills curriculum, that teach stress and coping skills and show promise in reducing suicidal ideation attempts and fatalities among AI/AN adolescents. Using a social-determinants-of-health lens, we review the availability and quality of employment as an important influencer of suicidal behavior, as well as the role of the workplace as an environment for suicide prevention in AI/AN communities. Working with tribal, state, local, and federal colleagues, the public health community can implement programs known to be effective and create additional comprehensive strategies to reduce inequities and ultimately reduce suicide rates.

Leveraging Social and Structural Determinants of Health at the Centers for Disease Control and Prevention: A Systems-Level Opportunity to Improve Public Health

CONTEXT

Social and structural determinants of health (SDOH) have become part of the public health and health care landscape. The need to address SDOH is reinforced by morbidity and mortality trends, including a recent multiyear decrease in life expectancy and persistent health disparities. Leadership on SDOH-related efforts has come from public health, health care, private philanthropy, and nongovernmental entities.

STRATEGY

The Centers for Disease Control and Prevention (CDC) has been addressing SDOH through both disease- or condition-specific programs and crosscutting offices. Guidance from public health partners in the field has led the CDC to consider more strategic approaches to incorporating SDOH into public health activities.

IMPLEMENTATION

The CDC's crosscutting SDOH Workgroup responded to external recommendations to develop a specific vision and plan that aims to integrate SDOH into the agency's infrastructure. The group also sponsors CDC forums for sharing research and trainings on embedding SDOH in programs. The group created a Web site to centralize CDC SDOH research, data sources, practice tools, programs, and policies.

PROGRESS

The CDC has shown strong leadership in prioritizing SDOH in recent years. Individual programs and crosscutting offices have developed various models aimed at ensuring that public health research and practice address SDOH.

DISCUSSION

Building sustainable SDOH infrastructures in public health institutions that reach across multiple health topics and non-health organizations could increase chances of meeting public health morbidity and mortality reduction goals, including decreasing health disparities. Although public health priorities and socioeconomic trends will change over time, experience suggests that social and structural factors will continue to influence the public's health. The CDC and state, tribal, local, and territorial public health institutions have played important leadership roles in the system of community and service organizations that interface with communities they mutually serve to address SDOH. Continued capacity-building could help grow and sustain an SDOH infrastructure that advances this work.

Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020

In the 10 months since the first confirmed case of coronavirus disease 2019 (COVID-19) was reported in the United States on January 20, 2020 (1), approximately 13.8 million cases and 272,525 deaths have been reported in the United States. On October 30, the number of new cases reported in the United States in a single day exceeded 100,000 for the first time, and by December 2 had reached a daily high of 196,227.* With colder weather, more time spent indoors, the ongoing U.S. holiday season, and silent spread of disease, with approximately 50% of transmission from asymptomatic persons (2), the United States has entered a phase of high-level transmission where a multipronged approach to implementing all evidence-based public health strategies at both the individual and community levels is essential. This summary guidance highlights critical evidence-based CDC recommendations and sustainable strategies to reduce COVID-19 transmission. These strategies include 1) universal face mask use, 2) maintaining physical distance from other persons and limiting in-person contacts, 3) avoiding nonessential indoor spaces and crowded outdoor spaces, 4) increasing testing to rapidly identify and isolate infected persons, 5) promptly identifying, quarantining, and testing close contacts of persons with known COVID-19, 6) safeguarding persons most at risk for severe illness or death from infection with SARS-CoV-2, the virus that causes COVID-19, 7) protecting essential workers with provision of adequate personal protective equipment and safe work practices, 8) postponing travel, 9) increasing room air ventilation and enhancing hand hygiene and environmental disinfection, and 10) achieving widespread availability and high community coverage with effective COVID-19 vaccines. In combination, these strategies can reduce SARS-CoV-2 transmission, long-term sequelae or disability, and death, and mitigate the pandemic's economic impact. Consistent implementation of these strategies improves health equity, preserves health care capacity, maintains the function of essential businesses, and supports the availability of in-person instruction for kindergarten through grade 12 schools and preschool. Individual persons, households, and communities should take these actions now to reduce SARS-CoV-2 transmission from its current high level. These actions will provide a bridge to a future with wide availability and high community coverage of effective vaccines, when safe return to more everyday activities in a range of settings will be possible.

Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations

This review describes the context of health equity and options for integrating equity into public health practice. We first discuss how the conceptualization of health equity and how equity considerations in US public health practice have been shaped by multidisciplinary engagements. We then discuss specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified.

Racial/Ethnic Health Disparities Among Rural Adults-United States, 2012-2015: <i>MMWR Surveillance Summaries</i> / November 17, 2017 / 66(23);1-9

PROBLEM/CONDITION

Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States.

REPORTING PERIOD

2012-2015.

DESCRIPTION OF SYSTEM

Self-reported data from the 2012-2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties.

RESULTS

Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days.

INTERPRETATION

Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary.

PUBLIC HEALTH ACTION

Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Circumstances Preceding Homicide-Suicides Involving Child Victims: A Qualitative Analysis

Homicide-suicide incidents involving child victims can have a detrimental impact on survivors of the violence, family members and friends of the decedents, and other community members, but the rare occurrence of these acts makes using quantitative data to examine their associated antecedents challenging. Therefore, using qualitative data from the 2003-2011 National Violent Death Reporting System, we examined 175 cases of homicide-suicide involving child victims in an effort to better understand the complex situational factors of these events. Our findings indicate that 98% of homicide-suicides with child victims are perpetrated by adults (mostly parents) and propelled by the perpetrators' intimate partner problems, mental health problems, and criminal/legal problems. These events are often premeditated, and plans for the violence are sometimes disclosed prior to its occurrence. Findings provide support for several theoretical perspectives, and implications for prevention are discussed.

Racial/Ethnic Health Disparities Among Rural Adults - United States, 2012-2015

PROBLEM/CONDITION

Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States.

REPORTING PERIOD

2012-2015.

DESCRIPTION OF SYSTEM

Self-reported data from the 2012-2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties.

RESULTS

Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days.

INTERPRETATION

Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary.

PUBLIC HEALTH ACTION

Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Examining the Prevalence and Predictors of Injury from Adolescent Dating Violence

Medical needs of youth who experience dating violence are not well understood because of limited past research examining the prevalence and predictors of injuries and medical help seeking. To address these gaps, the current study described the prevalence and predictors of injuries from dating violence from grades 8 through 12 in a large sample of youth. Results indicate that one third to one half of youth who experienced any physical and/or sexual dating violence also sustained an injury. Prevalence of injury was highest in the 8^th grade and was significantly higher for females than for males across grades 8 through 11. Youth who experienced greater amounts of violent victimization in their relationships (physical, sexual, and psychological) were at highest risk for injury. Results also suggest that victims at highest risk for injury are girls, white youth, those experiencing multiple types of violence, and those who also engage in perpetration. Given the high prevalence of injury among youth who report dating violence, healthcare professionals may be in a unique position to screen and counsel youth about dating violence. Because the highest prevalence of injury occurred before high school, prevention programs should start early and selected prevention may be used for youth at highest risk for injury.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

INTRODUCTION

While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.

PATIENTS AND METHODS

We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury."

RESULTS

3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.

CONCLUSIONS

Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

Laboratory evaluation of a novel anaesthesia delivery device

Here, we describe proof of concept of a novel method for delivering volatile anaesthetics, where the liquid anaesthetic (sevoflurane or isoflurane) is formulated into an emulsion that is contained in a compact, lightweight device through which carrier gas flows. Release of anaesthetic is achieved by stirring of the formulation, allowing controlled and responsive release of anaesthetic at a variety of fixed flow rates between 0.5 l.min^-1 and 5 l.min^-1 , with ventilated, non-ventilated and draw-over breathing systems. Anaesthetic release was evaluated using target anaesthetic concentrations ranging from 0.5% v/v to 8% v/v to mimic those typically required for induction and maintenance of anaesthesia, and lower concentrations suitable for sedation. Under all conditions, output could be maintained within 0.1% v/v of the intended setting, and the device could deliver a controlled level of anaesthetic for at least 60 min, with compensation for different ambient temperatures (10-30 °C) and carrier gas flow rates. This device offers a simple, inexpensive method of delivering safe concentrations of volatile anaesthetics for a wide range of applications.

Developing a digital data collection platform to measure the prevalence of sepsis in Wales

OBJECTIVE

To develop a secure, efficient, and easy-to-use data collection platform to measure the prevalence of sepsis in Wales over 24 hours.

MATERIALS AND METHODS

Open Data Kit was used on Android devices with Google App Engine and a digital data collection form.

RESULTS

A total of 184 students participated in the study using 59 devices across 16 hospitals, 1198 datasets were submitted, and 97% of participants found the Open Data Kit form easy to use.

DISCUSSION

We successfully demonstrated that by combining a reliable Android device, a free open-source data collection framework, a scalable cloud-based server, and a team of 184 medical students, we can deliver a low-cost, highly reliable platform that requires little training or maintenance, providing results immediately on completion of data collection.

CONCLUSION

Our platform allowed us to measure, for the first time, the prevalence of sepsis in Wales over 24 hours.

Gender Role Attitudes and Male Adolescent Dating Violence Perpetration: Normative Beliefs as Moderators

Commonly used dating violence prevention programs assume that promotion of more egalitarian gender role attitudes will prevent dating violence perpetration. Empirical research examining this assumption, however, is limited and inconsistent. The current study examined the longitudinal association between gender role attitudes and physical dating violence perpetration among adolescent boys (n = 577; 14 % Black, 5 % other race/ethnicity) and examined whether injunctive (i.e., acceptance of dating violence) and descriptive (i.e., beliefs about dating violence prevalence) normative beliefs moderated the association. As expected, the findings suggest that traditional gender role attitudes at T1 were associated with increased risk for dating violence perpetration 18 months later (T2) among boys who reported high, but not low, acceptance of dating violence (injunctive normative beliefs) at T1. Descriptive norms did not moderate the effect of gender role attitudes on dating violence perpetration. The results suggest that injunctive norms and gender role attitudes work synergistically to increase risk for dating violence perpetration among boys; as such, simultaneously targeting both of these constructs may be an effective prevention approach.

Compensatory Increase in Ovarian Aromatase in Older Regularly Cycling Women

CONTEXT

Serum estradiol (E2) levels are preserved in older reproductive-aged women with regular menstrual cycles despite declining ovarian function.

OBJECTIVE

The objective of the study was to determine whether increased granulosa cell aromatase expression and activity account for preservation of E2 levels in older, regularly cycling women.

DESIGN

The protocol included daily blood sampling and dominant follicle aspirations at an academic medical center during a natural menstrual cycle.

SUBJECTS

Healthy, regularly cycling older (36-45 y; n = 13) and younger (22-34 y; n = 14) women participated in the study.

MAIN OUTCOME MEASURES

Hormone levels were measured in peripheral blood and follicular fluid aspirates and granulosa cell CYP19A1 (aromatase) and FSH-R mRNA expression were determined.

RESULTS

Older women had higher FSH levels than younger women during the early follicular phase with similar E2 but lower inhibin B and antimullerian hormone levels. Late follicular phase serum E2 did not differ between the two groups. Follicular fluid E2 [older (O) = 960.0 [interquartile range (IQR) 765.0-1419.0]; younger (Y) = 994.5 [647.3-1426.5] ng/mL, P = 1.0], estrone (O = 39.6 [29.5-54.1]; Y = 28.8 [22.5-42.1] ng/mL, P = 0.3), and the E2 to testosterone (T) ratio (O = 109.0 ± 41.9; Y = 83.0 ± 18.6, P = .50) were preserved in older women. Granulosa cell CYP19A1 expression was increased 3-fold in older compared with younger women (P < .001), with no difference in FSH-R expression.

CONCLUSIONS

Ovarian aromatase expression increases with age in regularly cycling women. Thus, up-regulation of aromatase activity appears to compensate for the known age-related decrease in granulosa cell number in the dominant follicle to maintain ovarian estrogen production in older premenopausal women.

Control of respiratory and cardiovascular functions by leptin

Leptin, a peptide hormone produced by adipose tissue, acts in brain centers that control critical physiological functions such as metabolism, breathing and cardiovascular regulation. The importance of leptin for respiratory control is evident by the fact that leptin deficient mice exhibit impaired ventilatory responses to carbon dioxide (CO2), which can be corrected by intracerebroventricular leptin replacement therapy. Leptin is also recognized as an important link between obesity and hypertension. Humans and animal models lacking either leptin or functional leptin receptors exhibit many characteristics of the metabolic syndrome, including hyperinsulinemia, insulin resistance, hyperglycemia, dyslipidemia and visceral adiposity, but do not exhibit increased sympathetic nerve activity (SNA) and have normal to lower blood pressure (BP) compared to lean controls. Even though previous studies have extensively focused on the brain sites and intracellular signaling pathways involved in leptin effects on food intake and energy balance, the mechanisms that mediate the actions of leptin on breathing and cardiovascular function are only beginning to be elucidated. This mini-review summarizes recent advances on the effects of leptin on cardiovascular and respiratory control with emphasis on the neural control of respiratory function and autonomic activity.

Accumulated deep sleep is a powerful predictor of LH pulse onset in pubertal children

CONTEXT

During puberty, reactivation of the reproductive axis occurs during sleep, with LH pulses specifically tied to deep sleep. This association suggests that deep sleep may stimulate LH secretion, but there have been no interventional studies to determine the characteristics of deep sleep required for LH pulse initiation.

OBJECTIVE

The objective of this study was to determine the effect of deep sleep fragmentation on LH secretion in pubertal children.

DESIGN AND SETTING

Studies were performed in a clinical research center.

SUBJECTS

Fourteen healthy pubertal children (11.3-14.1 y) participated in the study.

INTERVENTIONS

Subjects were randomized to two overnight studies with polysomnography and frequent blood sampling, with or without deep sleep disruption via auditory stimuli.

RESULTS

An average of 68.1 ±10.7 (± SE) auditory stimuli were delivered to interrupt deep sleep during the disruption night, limiting deep sleep to only brief episodes (average length disrupted 1.3 ± 0.2 min vs normal 7.1 ± 0.8 min, P < .001), and increasing the number of transitions between non-rapid eye movement (NREM), REM, and wake (disrupted 274.5 ± 33.4 vs normal 131.2 ± 8.1, P = .001). There were no differences in mean LH (normal: 3.2 ± 0.4 vs disrupted: 3.2 ± 0.5 IU/L), LH pulse frequency (0.6 ± 0.06 vs 0.6 ± 0.07 pulses/h), or LH pulse amplitude (2.8 ± 0.4 vs 2.8 ± 0.4 IU/L) between the two nights. Poisson process modeling demonstrated that the accumulation of deep sleep in the 20 minutes before an LH pulse, whether consolidated or fragmented, was a significant predictor of LH pulse onset (P < .001).

CONCLUSION

In pubertal children, nocturnal LH augmentation and pulse patterning are resistant to deep sleep fragmentation. These data suggest that, even when fragmented, deep sleep is strongly related to activation of the GnRH pulse generator.

Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials

BACKGROUND

Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting.

METHODS

Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals.

RESULTS

Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)].

CONCLUSION

We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation.

Extracting drug mechanism and pharmacodynamic information from clinical electroencephalographic data using generalised semi-linear canonical correlation analysis

Conventional analysis of clinical resting electroencephalography (EEG) recordings typically involves assessment of spectral power in pre-defined frequency bands at specific electrodes. EEG is a potentially useful technique in drug development for measuring the pharmacodynamic (PD) effects of a centrally acting compound and hence to assess the likelihood of success of a novel drug based on pharmacokinetic-pharmacodynamic (PK-PD) principles. However, the need to define the electrodes and spectral bands to be analysed a priori is limiting where the nature of the drug-induced EEG effects is initially not known. We describe the extension to human EEG data of a generalised semi-linear canonical correlation analysis (GSLCCA), developed for small animal data. GSLCCA uses data from the whole spectrum, the entire recording duration and multiple electrodes. It provides interpretable information on the mechanism of drug action and a PD measure suitable for use in PK-PD modelling. Data from a study with low (analgesic) doses of the μ-opioid agonist, remifentanil, in 12 healthy subjects were analysed using conventional spectral edge analysis and GSLCCA. At this low dose, the conventional analysis was unsuccessful but plausible results consistent with previous observations were obtained using GSLCCA, confirming that GSLCCA can be successfully applied to clinical EEG data.

Evidence that increased ovarian aromatase activity and expression account for higher estradiol levels in African American compared with Caucasian women

CONTEXT

Serum estradiol levels are significantly higher across the menstrual cycle in African American (AAW) compared with Caucasian women (CW) in the presence of similar FSH levels, yet the mechanism underlying this disparity is unknown.

OBJECTIVE

The objective of the study was to determine whether higher estradiol levels in AAW are due to increased granulosa cell aromatase mRNA expression and activity.

DESIGN

The design of the study included daily blood sampling and dominant follicle aspirations at an academic medical center during a natural menstrual cycle.

SUBJECTS

Healthy, normal cycling AAW (n = 15) and CW (n = 14) aged 19-34 years participated in the study.

MAIN OUTCOME MEASURES

Hormone levels in peripheral blood and follicular fluid (FF) aspirates and aromatase and FSH receptor mRNA expression in granulosa cells were measured.

RESULTS

AAW had higher FF estradiol [1713.0 (1144.5-2032.5) vs 994.5 (647.3-1426.5) ng/mL; median (interquartile range); P < .001] and estrone [76.9 (36.6-173.4) vs 28.8 (22.5-42.1) ng/mL; P < .001] levels than CW, independent of follicle size. AAW also had lower FF androstenedione to estrone (7 ± 1.8 vs 15.8 ± 4.1; mean ± SE; P = .04) and T to estradiol (0.01 ± 0.002 vs 0.02 ± 0.005; P = .03) ratios, indicating enhanced ovarian aromatase activity. There was a 5-fold increase in granulosa cell aromatase mRNA expression in AAW compared with CW (P < .001) with no difference in expression of FSH receptor. FSH, inhibin A, inhibin B, and AMH levels were not different in AAW and CW.

CONCLUSIONS

Increased ovarian aromatase mRNA expression, higher FF estradiol levels, and decreased FF androgen to estrogen ratios in AAW compared with CW provide compelling evidence that racial differences in ovarian aromatase activity contribute to higher levels of estradiol in AAW across the menstrual cycle. The absence of differences in FSH, FSH receptor expression, and AMH suggest that population-specific genetic variation in CYP19, the gene encoding aromatase, or in factors affecting its expression should be sought.

Youth violence and connectedness in adolescence: what are the implications for later sexually transmitted infections?

PURPOSE

To examine associations between (1) youth violence victimization and perpetration and later sexually transmitted infections (STI) and (2) parent-family and school connectedness and later STI, and to explore the moderating role of connectedness on the associations between youth violence victimization and perpetration and later STI.

METHODS

We used data from Waves I and IV of the National Longitudinal Study of Adolescent Health, which provided a baseline weighted sample of 14,800 respondents. We used logistic regression to examine associations between youth violence and connectedness with self-reported ever STI diagnosis, including gonorrhea, chlamydia, syphilis, genital herpes, genital warts or human papillomavirus, or human immunodeficiency virus. If participants reported having an STI at Wave I they were excluded from the analysis.

RESULTS

Controlling for biological sex, race/ethnicity, age, parent's highest education level, and parent's marital status, both youth violence victimization and perpetration were associated with an increased risk of later STI (adjusted odds ratio [AOR], 1.27, 95% confidence interval [CI], 1.07-1.52; and AOR, 1.21, 95% CI, 1.04-1.41, respectively). Parent-family and school connectedness in adolescence were associated with a decreased risk for later STI (AOR, .96, 95% CI, .95-.98; and AOR, .97, 95% CI, .95-.99, respectively); however, connectedness did not moderate the associations between nonsexual violence involvement and later STI.

CONCLUSIONS

These results indicate that youth violence victimization and perpetration may be risk factors for STI later in life. Conversely, parent-family and school connectedness in adolescence appear to protect against subsequent STI. The findings suggest that provider efforts to address youth violence and connectedness in adolescence can promote positive sexual health outcomes in adulthood.

Role of Shp2 in forebrain neurons in regulating metabolic and cardiovascular functions and responses to leptin

Objective

We examined whether deficiency of Shp2 signaling in forebrain neurons alters metabolic and cardiovascular regulation under various conditions and if it attenuates the anorexic and cardiovascular effects of leptin. We also tested whether forebrain Shp2 deficiency alters blood pressure (BP) and heart rate (HR) responses to acute stress.

Design

Forebrain Shp2^-/- mice were generated by crossing Shp2^flox/flox mice with CamKIIα-cre mice. At 22 to 24 weeks of age, mice were instrumented for telemetry for measurement of BP, HR and body temperature (BT). Oxygen consumption (VO2), energy expenditure and motor activity were monitored by indirect calorimetry.

Results

Shp2/CamKIIα-cre mice were heavier (46±3 vs 32±1 g), hyperglycemic, hyperleptinemic, hyperinsulinemic, and hyperphagic compared to Shp2^flox/flox control mice. Shp2/CamKIIα-cre mice exhibited reduced food intake responses to fasting/refeeding and impaired regulation of BT when exposed to 15°C and 30°C ambient temperatures. Despite being obese and having many features of metabolic syndrome, Shp2/CamKIIα-cre mice had similar daily average BP and HR compared to Shp2^flox/flox mice (112±2 vs 113±1 mmHg and 595±34 vs 650±40 bpm), but exhibited increased BP and HR responses to cold exposure and acute air-jet stress test. Leptin's ability to reduce food intake and to raise BP were markedly attenuated in Shp2/CamKIIα-cre mice.

Conclusion

These results suggest that forebrain Shp2 signaling regulates food intake, appetite responses to caloric deprivation, and thermogenic control of body temperature during variations in ambient temperature. Deficiency of Shp2 signaling in the forebrain is associated with augmented cardiovascular responses to cold and acute stress but attenuated BP responses to leptin.

Global consensus statement on menopausal hormone therapy

The following Consensus Statement is endorsed by The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society.

Expanding Resource Theory and Feminist-Informed Theory to Explain Intimate Partner Violence Perpetration by Court-Ordered Men

This study tested resource and feminist-informed theories to explain physical, sexual, psychological, and stalking intimate partner violence (IPV) perpetrated by court-mandated men. Data were obtained from 340 men arrested for physical assault of a partner before their court-ordered treatment. Using path analysis, findings provided partial support for each model. Ineffective arguing and substance-use problems were moderators of resources and perpetration. Dominance mediated early exposures and perpetration in the feminist-informed model. In both models, predictors of stalking were different than those for other types of perpetration. Future studies should replicate this research and determine the utility of combining models.

Homicide-followed-by-suicide incidents involving child victims

OBJECTIVES

To describe homicide-followed-by-suicide incidents involving child victims

METHODS

Using 2003-2009 National Violent Death Reporting System data, we characterized 129 incidents based on victim and perpetrator demographic information, their relationships, the weapons/mechanisms involved, and the perpetrators' health and stress-related circumstances.

RESULTS

These incidents accounted for 188 child deaths; 69% were under 11 years old, and 58% were killed with a firearm. Approximately 76% of perpetrators were males, and 75% were parents/caregivers. Eighty-one percent of incidents with paternal perpetrators and 59% with maternal perpetrators were preceded by parental discord. Fifty-two percent of incidents with maternal perpetrators were associated with maternal psychiatric problems.

CONCLUSIONS

Strategies that resolve parental conflicts rationally and facilitate detection and treatment of parental mental conditions might help prevention efforts.

Insights into puberty: the relationship between sleep stages and pulsatile LH secretion

CONTEXT

During the pubertal transition, LH secretion initially increases only during sleep; however, its relationship to sleep stage is unknown.

OBJECTIVES

Our objective was to determine whether the initiation of LH pulses is related to a specific sleep stage in pubertal children.

DESIGN AND SETTING

Frequent blood sampling and polysomnographic studies were performed in a Clinical Research Center.

SUBJECTS

Fourteen studies were performed in nine healthy pubertal children, ages 9.9-15.6 yr.

INTERVENTIONS

Subjects underwent one to two overnight studies with polysomnography and blood sampling for LH at 10-min intervals.

RESULTS

Alignment of polysomnographic records and LH pulses demonstrated that LH pulses (n = 58) occurred most frequently during slow-wave sleep (SWS) (1.1 pulse/h, n = 30) compared with all other sleep stages or periods of wake after sleep onset (P < 0.001). There was also a significant increase in the amount of SWS in the 15 min preceding and the 5 min following each pulse compared with the amount of SWS seen across the study night (P < 0.01).

CONCLUSIONS

During puberty, the majority of LH pulses that occur after sleep onset are preceded by SWS, suggesting that SWS is intimately involved in the complex control of pubertal onset. These studies raise concerns about the potential hormonal repercussions of the increasing prevalence of sleep disturbances in adolescents.

Sex, race/ethnicity, and context in school-associated student homicides

This study assessed the importance of sex, race/ethnicity, and geographic context for incidents of school-associated student homicides between July 1, 1994 and June 30, 1999, covering 5 academic years. Using data from the Centers for Disease Control and Prevention School Associated Violent Deaths Study (n = 125 incidents), we compared percentages and medians of victim, offender, motive, and school characteristics for incidents by geographic context and race/ethnicity of the offenders. Most incidents involved urban areas (53.6%), Black and Latino offenders and victims, moderately high youth poverty, and male on male violence (77.6%) driven by disputes and gang-related motives. Suburban area incidents (31.2%) often involved offenders and victims of a different race/ethnicity (51.3%). Multiple victims and White offenders were more common in rural areas (15.2%). More than 50% of the rural incidents involved male offenders and female victims. White offender incidents more often included multiple victims and female victims while Black and Latino offenders more often included single victims of the same sex. These results emphasize the utility of an incident-based analysis of school-associated student homicides in highlighting important variations by intersections of sex, race/ethnicity, and geographic context.

Implications of direct protective factors for public health research and prevention strategies to reduce youth violence

The development of work on direct protective factors for youth violence has been delayed by conceptual and methodologic problems that have constrained the design, execution, and interpretation of prevention research. These problems are described in detail and actively addressed in review and analytic papers developed by the CDC's Expert Panel on Protective Factors for youth violence. The present paper synthesizes findings from these papers, specifies their implications for public health research and prevention strategies to reduce youth violence, and suggests directions for future research.

Centers for Disease Control and Prevention's Expert Panel on Protective Factors for Youth Violence Perpetration: background and overview

The CDC Expert Panel on Protective Factors for Youth Violence Perpetration was convened to review and advance the status of etiologic and prevention research on direct protective and buffering protective factors for youth violence perpetration. The current paper introduces Phase One of the panel's work, which focuses on direct protective factors and includes the papers in this supplement to the American Journal of Preventive Medicine. This paper provides the context for the panel's work, describes its practical and theoretic importance, and summarizes why independently defined direct protective factors and risk factors are important for the advancement of our understanding of youth violence and its prevention. Lastly, this paper briefly describes the organization of the work of the panel as well as the research products that comprise the contents of the supplement.

Inhibition of soluble epoxide hydrolase reduces food intake and increases metabolic rate in obese mice

BACKGROUND AND AIMS

This study evaluated the responses to soluble epoxide hydrolase (s-EH) inhibition, an essential enzyme in the metabolism of arachidonic acid, on food intake, body weight and metabolic parameters in mice fed a high fat-high fructose diet (HFD) for 10 weeks.

METHODS AND RESULTS

After 5 weeks of HFD, mice were divided into two groups: 1) s-EH inhibitor (AR9281, 200mg/kg/day by gavage twice daily), and 2) vehicle (0.3ml per gavage). Food intake, body weight, oxygen consumption (VO(2)), carbon dioxide production (VCO(2)), respiratory quotient (RQ), and motor activity were measured weekly for more 5 weeks. HFD increased body weight (37±1 vs. 26±1g), and plasma of glucose (316±8 vs. 188±27mg/dl), insulin (62.1±8.1 vs. 15.5±5.0μU/ml), and leptin levels (39.4±3.6 vs. 7.5±0.1ng/ml) while reducing VO(2), VCO(2) and motor activity. s-EH inhibition for 5 weeks decreased caloric intake by ~32% and increased VO(2) by ~17% (42.8±1.4 vs. 50.2±1.5ml/kg/min) leading to significant weight loss. Inhibition of s-EHi also caused significant reductions in plasma leptin levels and visceral fat content. Uncoupling protein 1 (UCP1) content in brown adipose tissue was also elevated by ~50% during s-EH inhibition compared to vehicle treatment.

CONCLUSION

These results suggest that s-EH inhibition with AR9281 promotes weight loss by reducing appetite and increasing metabolic rate, and that increased UCP1 content may contribute to the increase in energy expenditure.

Intimate partner violence perpetration by court-ordered men: distinctions among subtypes of physical violence, sexual violence, psychological abuse, and stalking

This study continues previous work documenting the structure of violence perpetrated by males against their female intimate partners. It assesses the construct validity of a measurement model depicting associations among eight subtypes of perpetration: moderate physical violence, severe physical violence, forced or coerced sexual violence, sexual violence where consent was not possible, emotional/verbal psychological abuse, dominance/isolation psychological abuse, interactional contacts/surveillance related stalking, and stalking involving mediated contacts. Data were obtained from a sample of 340 men arrested for physical assault of a female spouse or partner, and court ordered into batterer intervention programs. Men were surveyed before starting the intervention. Confirmatory factor analyses (CFA) supported the validity of model as evidenced by good model to data fit and satisfaction of requirements for fit statistics. In addition, the eight factor solution was characterized by a slightly better model to data fit than a four factor higher order solution described in the author's previous work. Latent variable correlations across the broader categories of intimate partner violence (IPV) revealed that the violence subtypes were mostly moderately positively correlated and ranged from .381 (emotional/verbal psychological abuse with interactional contacts/surveillance related stalking) to .795 (dominance/isolation psychological with abuse with forced sex). Future studies should determine whether there are distinct risk factors and health outcomes associated with each of the eight IPV perpetration subtypes and identify possible patterns of co-occurrence.

Complement takes its Toll: an inflammatory crosstalk between Toll-like receptors and the receptors for the complement anaphylatoxin C5a

The innate immune system is responsible for a rapid inflammatory response to pathogens that is essential for the clearance of infections. Although this response is vital, it is nonetheless potentially harmful, and dysregulated inflammation is a feature of many disease states. Thus, the mechanisms that regulate the release of soluble mediators of inflammation are an active focus of investigation. The activation by infections of two key components of the innate immune system, the Toll-like receptors (TLRs) and complement, leading to the release of soluble mediators of inflammation, is critical to microbial killing and clearance. Both TLRs and complement are independently capable of triggering pro-inflammatory responses, but their synergistic interaction resulting from a substantial crosstalk markedly amplifies those responses and may contribute to the pathophysiology of diseases such as sepsis.

Gonadotropin responses to estrogen-positive and -negative feedback are identical in African-American and Caucasian women

CONTEXT

Gonadotropin levels are similar in African-American women (AAW) and Caucasian women (CW), despite higher preovulatory estradiol (E2) levels in AAW, suggesting that AAW may be less sensitive to E2 feedback than CW.

OBJECTIVE

The aim of the study was to determine whether responsivity to estrogen feedback differs in AAW and CW.

DESIGN AND SETTING

Subjects were studied in the early follicular phase using a 5-d, graded E2 and progesterone infusion.

SUBJECTS

Healthy, normal-cycling AAW (n = 10) and CW (n = 13) aged 23-30 yr participated in the study.

MAIN OUTCOME MEASURES

Blood samples were collected every 4 h and assayed for LH, FSH, E2, and progesterone.

RESULTS

There was no difference in E2-negative feedback on LH (nadir, 3.8 ± 0.4 vs. 5.4 ± 0.9 IU/liter; time of nadir, 33.2 ± 3.3 vs. 32.3 ± 2.7 h) or FSH (nadir, 3.1 ± 0.4 vs. 3.1 ± 0.3 IU/liter; time of nadir, 48.8 ± 2.7 vs. 50.5 ± 3.1 h) in AAW compared to CW. The two groups also demonstrated similar positive feedback responses of E2 on LH (peak, 80.3 ± 13.3 vs. 73.1 ± 11.6 IU/liter; time of peak, 80.4 ± 4.3 vs. 86.5 ± 3.1 h) and FSH (peak, 13.4 ± 1.4 vs. 10.2 ± 1.0 IU/liter; time of peak, 82.2 ± 4.0 vs. 97.2 ± 4.9 h).

CONCLUSIONS

LH and FSH feedback responses to a controlled steroid infusion do not differ between AAW and CW, indicating that AAW do not have diminished hypothalamic-pituitary responsivity to E2. These studies support the concept of a threshold effect of E2 in generating LH-positive feedback, suggest pituitary insensitivity to differences in E2 of the magnitude observed in prior studies, and account for similarities in gonadotropins despite E2 differences in AAW compared with CW.

A novel HLA-A*30 allele, HLA-A*30:36

A novel HLA allele, HLA-A*30:36, is found in a donor from the Central German Bone Marrow Donor Registry.

Estrogen levels are higher across the menstrual cycle in African-American women compared with Caucasian women

CONTEXT

Previous studies have suggested that estrogen levels may be higher in African-American women (AAW) compared with Caucasian women (CW), but none have systematically examined estrogen secretion across the menstrual cycle or in relation to other reproductive hormones.

OBJECTIVE

The objective of the study was to compare estradiol (E2), progesterone (P), gonadotropins, androstenedione (a'dione), inhibins, and SHBG levels between AAW and CW across the menstrual cycle.

DESIGN, SETTING, AND SUBJECTS

Daily blood samples were collected from regularly cycling AAW (n = 27) and CW (n = 27) for a full menstrual cycle, and serial ultrasounds were performed.

MAIN OUTCOME MEASURES

Comparison of E2, P, LH, FSH, SHBG, inhibin A, inhibin B, and a'dione levels.

RESULTS

AAW and CW were of similar age (27.2 ± 0.6 yr, mean ± sem) and body mass index (22.7 ± 0.4 kg/m(2)). All subjects grew a single dominant follicle and had comparable cycle (25-35 d) and follicular phase (11-24 d) lengths. E2 levels were significantly higher in AAW compared with CW (P = 0.02) with the most pronounced differences in the late follicular phase (225.2 ± 14.4 vs. 191.5 ± 10.2 pg/ml; P = 0.02), midluteal phase (211.9 ± 22.2 vs.150.8 ± 9.9, P < 0.001), and late luteal phase (144.4 ± 13.2 vs. 103.5 ± 8.5, P = 0.01). Although LH, FSH, inhibins A and B, P, a'dione, and SHBG were not different between the two groups, the a'dione to E2 ratio was lower in AAW (P < 0.001).

CONCLUSIONS

Estradiol is higher in AAW compared with CW across the menstrual cycle. Higher estradiol in the face of similar androstenedione and FSH levels suggests enhanced aromatase activity in AAW. Such differences may contribute to racial disparities in bone mineral density, breast cancer, and uterine leiomyomas.

Assessment of thrombin generation measured before and after cardiopulmonary bypass surgery and its association with postoperative bleeding

BACKGROUND

Bleeding after cardiopulmonary bypass (CPB) is a major cause of morbidity and mortality and consumes large amounts of blood. Identifying patients at increased risk of bleeding secondary to hemostatic impairment may improve clinical outcomes by allowing early intervention.

METHODS

This present study recruited 77 patients undergoing CPB and measured coagulation screens, coagulation factors, TEG(®), Rotem(®) and thrombin generation (TG) before surgery and 30 min after heparin reversal. The tests were analyzed to investigate whether they identified patients at increased risk of excess bleeding (defined as > 1000 mL) in the first 24 h postoperatively.

RESULTS

Patients who bled > 1000 mL had a lower: platelet count (P < 0.02), factors (F)IX, X and XI (P < 0.005), endogenous thrombin potential (ETP) and an initial rate of TG (P < 0.02) and higher activated partial thromboplastin time (aPTT) (P < 0.001) than patients who bled < 1000 mL. Receiver operating characteristic (ROC) analysis was significant for post-operative TG and aPTT (P < 0.001). Furthermore, reduced pre-operative TG was associated with increased postoperative bleeding (P < 0.02). Pre- and postoperative TG were correlated (ρ = 0.7, P < 0.001). TEG(®), Rotem(®) and prothrombin time (PT) at either time point were not associated with increased bleeding.

CONCLUSION

These data suggest that pre-operative defects in the propagation phase of hemostasis are exacerbated during CPB, contributing to bleeding post-CPB. TG taken both pre- and postoperatively could potentially be used to identify patients at an increased risk of bleeding post-CPB.

Intimate partner violence perpetration by court-ordered men: distinctions and intersections among physical violence, sexual violence, psychological abuse, and stalking

This study assessed the construct validity of two different measurement models of male partners' perpetration of physical violence, sexual violence, psychological abuse, and stalking against intimate partners. Data were obtained from a sample of 340 men arrested for physical assault of a female spouse or partner and court ordered into batterer intervention programs. Men were surveyed before starting the intervention. Confirmatory factor analysis (CFA) was used to compare the construct validity of a four-factor measurement model of intimate partner violence (IPV) perpetration to a three-factor measurement model that combined psychological abuse with stalking; overlap in the perpetration of the various forms of IPV was also examined. CFA results supported the superiority of a four-factor measurement model. There were 96.8% of participants who reported perpetration of all four types of violence; most men perpetrated multiple types of violence. Future studies should determine whether there are distinct risk factors associated with each of the four types of IPV perpetration.

Estrogen negative feedback on gonadotropin secretion: evidence for a direct pituitary effect in women

CONTEXT

Studies in humans and animals indicate that estrogen negative feedback occurs at the level of the hypothalamus, but it is unclear whether estrogen also exerts an inhibitory effect directly at the pituitary.

OBJECTIVES

The aim of the study was to determine whether estrogen has a direct negative feedback effect at the pituitary and whether this varies with aging.

DESIGN AND SETTING

A GnRH antagonist and graded doses of GnRH were used to isolate pituitary responsiveness before and after estrogen administration in Clinical Research Center studies at an academic medical center.

SUBJECTS

Subjects were healthy postmenopausal women aged 48-56 yr (n = 8) or 70-75 yr (n= 8).

INTERVENTIONS

A suppressive dose of the NAL-GLU GnRH antagonist was administered, followed by graded doses of GnRH before and after 1 month of estrogen administration.

RESULTS

LH and FSH responses to GnRH decreased after estrogen administration (P = 0.01 and P = 0.0001, respectively). The ratio of FSH to LH amplitudes decreased in response to estrogen (P = 0.04) indicating a greater sensitivity of FSH than LH to inhibition by estrogen. The inhibitory effect of estrogen on FSH was attenuated with aging (P = 0.02), but was maintained for LH (P = 0.4).

CONCLUSIONS

Studies that control for endogenous GnRH and estradiol demonstrate a direct pituitary site of estrogen negative feedback on LH and FSH responsiveness to GnRH in women. The effect of estrogen on FSH responsiveness is greater than on LH and is attenuated with aging. These studies indicate that estrogen negative feedback occurs directly at the pituitary and contributes to the differential regulation of FSH and LH secretion.

Criteria for polycystic ovarian morphology in polycystic ovary syndrome as a function of age

CONCEPT

Ovaries meeting criteria for polycystic ovary morphology during peak reproductive years may no longer meet the criteria with age.

OBJECTIVE

Ovarian volume and follicle number decrease with age in women with polycystic ovary syndrome (PCOS), permitting age-dependent criteria for PCOM.

DESIGN AND SETTING

We conducted longitudinal (7-15 year interval) and cross-sectional studies to examine polycystic ovarian morphology over time at an outpatient clinic and pathology laboratory in a tertiary care hospital.

PATIENTS

Subjects included those with PCOS defined by the National Institutes of Health criteria (n = 11 and 483 for longitudinal and cross-sectional, respectively) and control women with regular menstrual cycles and no hyperandrogenism (n = 15 and 367), age 18-64 yr.

INTERVENTIONS

Subjects underwent an ovarian ultrasound by a single observer.

MAIN OUTCOME MEASURES

Ovarian volume and follicle number were measured and ultrasound findings confirmed by a pathologist in a subset (n = 9).

RESULTS

Ovarian volume (15.2 +/- 7.4 vs. 7.1 +/- 3.7 ml; P < 0.01) and follicle number (12.8 +/- 3.2 vs. 8.1 +/- 3.9; P < 0.05) decreased longitudinally in PCOS and control women (volume 11.6 +/- 4.4 vs. 5.4 +/- 2.2 ml and follicle number 8.3 +/- 1.9 vs. 6.3 +/- 1.8; both P < 0.005). Using cross-sectional data, log ovarian volume and follicle number decreased in both groups, but the decrease in log ovarian volume was less pronounced in women with PCOS than in controls (P < 0.01). A combination of age, log ovarian volume, follicle number, and testosterone distinguished PCOS subjects from controls with a receiver operator characteristic curve area of 0.90.

CONCLUSIONS

Ovarian volume and follicle number decrease with age in women with PCOS and controls necessitating age-based criteria to define polycystic ovarian morphology. It is possible to use these criteria to distinguish PCOS in women over age 40 yr.

Angiotensin II natriuresis and antinatriuresis: role of renal artery pressure, renal hemodynamics, and tubular reabsorption

The aim of this study was to determine the role of changes in renal artery pressure (RAP), renal hemodynamics, and tubular reabsorption in mediating the natriuretic and antinatriuretic actions of angiotensin II (AII). In anesthetized dogs, endogenous AII formation was blocked with SQ-14225 and AII was infused i.v. at rates of 5-1215 ng/kg/min while RAP was either servo-controlled at the normal level or permitted to increase. When RAP was servo-controlled to prevent a rise i RAP, AII infusion at all rates from 5-1215 ng/kg/min decreased urinary sodium excretion (UNaV) and fractional sodium excretion (FENa), while increasing fractional reabsorption of lithium (FRLi), an index of proximal tubule fractional sodium reabsorption and distal fractional sodium reabsorption (FRDNa): When RAP was permitted to increase, AII infusion rates up to 45 ng/kg/min decreased UNaV, and FENa, while increasing FRLi and FRDNa. However, at 135 ng/kg/min and above, UNaV and FENa increased while FRLi and FRDNa decreased when RAP was allowed to rise, even though RBF and FF were not substantially different from the values observed when RAP was servo-controlled. Filtered sodium load was slightly higher when RAP was permitted to increase during AII infusion, compared to the dogs in which RAP was servo-controlled, although the differences were not statistically significant. Thus, even very large doses of AII cause antinatriuresis when RAP was prevented from increasing. The natriuretic effect of high dose of AII is caused by increased RAP which decreases fractional sodium reabsorption in proximal and distal tubules and causes slight increases in sodium delivery to the tubules.

Bispectral Index asymmetry and COMFORT score in paediatric intensive care patients

BACKGROUND

The Bispectral Index (BIS) monitor has been suggested as a potential tool to measure depth of sedation in paediatric intensive care unit (PICU) patients. The primary aim of our observational study was to assess the difference in BIS values between the left and right sides of the brain. Secondary aims were to compare BIS and COMFORT score and to assess change in BIS with tracheal suctioning.

METHODS

Nineteen ventilated and sedated PICU patients had paediatric BIS sensors applied to either side of their forehead. Each patient underwent physiotherapy involving tracheal suctioning. Their BIS data and corresponding COMFORT score, assessment as by their respective nurses, were recorded before, during, and after physiotherapy.

RESULTS

Seven patients underwent more than one physiotherapy session; therefore, 28 sets of data were collected. The mean BIS difference values (and 95% CI) between left BIS and right BIS for pre-, during, and post-physiotherapy periods were 9.2 (5.9-12.5), 15.8 (11.9-19.7), and 7.5 (5.2-9.7), respectively. Correlation between mean BIS, left brain BIS, and right brain BIS to COMFORT score was highly significant (P<0.001 for all three) during the pre- and post-physiotherapy period, but less so during the stimulated physiotherapy period (P=0.044, P=0.014, and P=0.253, respectively).

CONCLUSIONS

A discrepancy between left and right brain BIS exists, especially when the patient is stimulated. COMFORT score and BIS correlate well between light and moderate sedation.

User satisfaction and forces generated during laryngoscopy using disposable Miller blades: a manikin study

Increasing awareness of prion-related diseases has led to an increase in the number of disposable laryngoscope blades available. We compared 11 disposable and standard re-usable Miller size 1 blades. In this manikin-based study, we studied user satisfaction for field of view at laryngoscopy, build quality and users' willingness to use the blade in an emergency situation. These were found to be better with metal disposable blades (p</=0.001). Vertical and horizontal forces developed during laryngoscopy were greater with plastic than with metal blades.

A comparison of the disposable Ambu�AuraOnce?Laryngeal Mask with the reusable LMA Classic?laryngeal mask airway

Single-use supraglottic airway devices are now available and are intended to be comparable with the reusable LMA Classic laryngeal mask airway. We performed a randomised cross-over study comparing the Ambu AuraOnce Laryngeal Mask with the LMA Classic. Fifty patients participated in the trial. Success rates for insertion at the first attempt were similar (92% with the Ambu and 84% with the LMA Classic; p = 0.22). The volumes of air required to inflate the cuff to produce a seal were similar, but the cuff pressure was lower for the Ambu Laryngeal Mask (median (IQR [range]) 18 (10-31 [0-100] cmH(2)O) than the LMA Classic 27 (17-50 [4-90] cmH(2)O; p = 0.007). Visual analogue scores for ease of insertion were 87 (73-93 [26-97]) mm for the Ambu and 84 (60-89 [18-96]) for the LMA Classic (p = 0.017). Complications were similar in both groups. We suggest that the disposable Ambu Laryngeal Mask is an acceptable alternative to the reusable LMA Classic.