The relationship between klotho, testosterone, and sexual health parameters among US adult men

BACKGROUND

Klotho is a pleotropic hormone involved in a multitude of biological processes necessary for healthy aging, and affords protection from adverse events such as cardiovascular disease, inflammation, and various cancers. Emerging evidence suggests that klotho is also an important component of biochemical pathways that regulate hormone balance, which may include those pathways governing testosterone production and men's sexual health, though data are limited and results are mixed.

OBJECTIVE

Using a cohort of 767 men from the NHANES 2015-2016 survey cycle, we set out to quantify the association between serum klotho levels and serum testosterone levels, as well as clinical markers of men's sexual health (e.g., testosterone:estrogen ratio, bioavailable testosterone, and free testosterone).

METHODS

Multivariable linear and logistic regression models while controlling for potential confounders were constructed to quantify the relationship between serum klotho and testosterone, as well as between serum klotho and odds of low testosterone (serum testosterone < 300 ng/dL).

RESULTS

A positive association was observed between serum klotho and testosterone (β = 0.18, p = 0.04). Serum klotho levels were also stratified into quartiles, and we observed statistically significant increases in testosterone for increasing quartile level of klotho using the first quartile as the reference group (β = 90.51, p = 0.001, β = 106.93, p = 0.002, β = 95.33, p = 0.03 for quartiles 2, 3, and 4, respectively). The average testosterone values by quartiles of klotho were 306.9 ng/dL, 390 ng/dL, 409.3 ng/dL, and 436.6 ng/dL, respectively. We modeled important proxies for sexual health including bioavailable and free testosterone, the testosterone:estradiol ratio, and C-reactive protein. Men in the second quartile of klotho had a significantly lower odds of an abnormal testosterone:estradiol ratio compared to the first quartile [OR = 0.18, 95% CI = (0.03, 0.98)].We observed null associations between continuous serum klotho and odds of low testosterone [OR = 1.0, 95% CI = (1.0, 1.0)], and when stratified by quartile, we observed a significant decrease in the odds of low testosterone for individuals in the second quartile of klotho compared to the first quartile [OR = 0.21, 95% CI = (0.05, 0.91)]. In addition, C-reactive protein was inversely associated with testosterone in men (β = - 4.65, p = 0.001), and inversely associated with quartiles of klotho (β = - 2.28, p = 0.04, β = - 2.22, p = 0.04, β = - 2.28, p = 0.03, for quartiles 2, 3, and 4, respectively).

CONCLUSION

Our findings support previous studies suggesting a role for klotho in testosterone levels and sexual function among men. Future studies are warranted to corroborate these findings, determine clinical significance, and elucidate potential mechanisms underlying these associations.

Building bridges between natural and social science disciplines: a standardized methodology to combine data on ecosystem quality trends

Despite a growing interest in interdisciplinary research, systematic ways of how to integrate data from different disciplines are still scarce. We argue that successful resource management relies on two key data sources: natural science data, which represents ecosystem structure and processes, and social science data, which describes people's perceptions and understanding. Both are vital, mutually complementing information sources that can underpin the development of feasible and effective policies and management interventions. To harvest the added value of combined knowledge, a uniform scaling system is needed. In this paper, we propose a standardized methodology to connect and explore different types of quantitative data from the natural and social sciences reflecting temporal trends in ecosystem quality. We demonstrate this methodology with different types of data such as fisheries stocks and mangrove cover on the one hand and community's perceptions on the other. The example data are collected from three United Nations Educational Scientific and Cultural Organization (UNESCO) Biosphere reserves and one marine park in Southeast Asia. To easily identify patterns of convergence or divergence among the datasets, we propose heat maps using colour codes and icons for language- and education-independent understandability. Finally, we discuss the limitations as well as potential implications for resource management and the accompanying communication strategies.

This article is part of the theme issue ‘Nurturing resilient marine ecosystems’.

Oral delivery of Hyperimmune bovine serum antibodies against CS6-expressing enterotoxigenic Escherichia coli as a prophylactic against diarrhea

BACKGROUND

. Oral administration of bovine antibodies active against enterotoxigenic Escherichia coli (ETEC) have demonstrated safety and efficacy against diarrhea in human challenge trials. The efficacy of bovine serum immunoglobulins (BSIgG) against recombinant colonization factor CS6 or whole cell ETEC strain B7A was assessed against challenge with the CS6-expressing B7A.

METHODS

. This was a randomized, double-blind, placebo-controlled trial in which healthy adults received oral hyperimmune BSIgG anti-CS6, anti-B7A whole cell killed or non-hyperimmune BSIgG (placebo) in a 1:1:1 ratio then challenged with ETEC B7A. Two days pre-challenge, volunteers began a thrice daily, seven day course of immunoprophylaxis. On day 3, subjects received 1 × 10¹⁰ CFUs of B7A. Subjects were observed for safety and the primary endpoint of moderate-severe diarrhea (MSD).

RESULTS

. A total of 59 volunteers received product and underwent ETEC challenge. The BSIgG products were well-tolerated across all subjects. Upon challenge, 14/20 (70%) placebo recipients developed MSD, compared to 12/19 (63%; p = .74) receiving anti-CS6 BSIgG and 7/20 (35%; p = .06) receiving anti-B7A BSIgG. Immune responses to the ETEC infection were modest across all groups.

CONCLUSIONS

. Bovine-derived serum antibodies appear safe and well tolerated. Antibodies derived from cattle immunized with whole cell B7A provided 50% protection against MSD following B7A challenge; however, no protection was observed in subjects receiving serum antibodies targeting CS6. The lack of observed efficacy in this group may be due to low CS6 surface expression on B7A, the high dose challenge inoculum and/or the use of serum derived antibodies versus colostrum-derived antibodies.

Mental health plan for workers of the London Nightingale Hospital: following the evidence to support staff

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces.

Unmet needs in ankylosing spondylitis patients receiving tumour necrosis factor inhibitor therapy; results from a large multinational real-world study

Background

Symptoms and comorbidities of ankylosing spondylitis (AS) considerably reduce health-related quality of life (HRQoL) and ability to work. This real-world study assessed rates of tumour necrosis factor inhibitor (TNFi) use and switching, treatment failure, and associations between failing TNFi and HRQoL, work productivity and activity impairment (WPAI).

Methods

AS patients and their treating physicians completed questionnaires capturing patient demographics, clinical status, TNFi treatment history, reasons for switching TNFi, HRQoL and WPAI. Current TNFi was determined as “failing” if, after ≥3 months, physician-rated disease severity had worsened, remained severe, was “unstable/deteriorating”, physicians were dissatisfied with disease control and/or did not consider treatment a “success”.

Results

The analysis included 2866 AS patients from 18 countries. Of 2795 patients with complete treatment data, 916 (32.8%) patients had never received TNFi therapy, 1623 (58.1%) patients were receiving their 1st TNFi and 200 (7.2%) patients had ever received ≥2 TNFi (treatment switch). Primary or secondary lack of efficacy were the commonest reasons for switching, and the mean delay in switching after primary lack of efficacy was 11.1 months. 232 (15.4%) patients on TNFi were currently “failing” who, compared to those with treatment success, reported poorer HRQoL: 5-dimension EuroQoL (EQ-5D-3 L): 0.63 vs. 0.78; Medical Outcomes Study Short-Form Health Survey version 2 (SF-36v2) mental component summary (MCS): 41.8 vs. 46.3; physical component summary (PCS): 40.2 vs. 45.1; impaired work productivity: 46.4% vs. 25.0%; and activity: 44.5% vs. 29.6%; all P < 0.001.

Conclusions

Among AS patients, switching TNFi is uncommon and delayed by nearly 1 year despite primary lack of efficacy. Patients currently failing TNFi experience worse physical function, HRQoL and work productivity.

206 Towards the generation of transchromosomic goats for the production of fully human immunoglobulin

We have previously reported that inactivation of endogenous immunoglobulin (Ig) genes can enhance the production of human polyclonal antibodies (hpAb) in transchromosomic (Tc) cattle containing a human artificial chromosome (HAC) comprising the entire human Ig gene repertoire. Goats offer the advantages of having a shorter gestation period and growing to adult size much faster than larger ungulates. Therefore, based upon our previously established Tc cattle platform, in this study, we aimed to generate immunoglobulin lambda light chain knockout (IGLλ −/− )/HAC Tc goats expressing hpAb using CRISPR/Cas9 and somatic cell nuclear transfer (SCNT) techniques. First, we designed multiple specific single-guide RNAs (sgRNA) targeting the coding sequences of constant regions of goat IGLλ1, IGLλ2 (both in NC_030824.1), and IGLλ3 (NW_017189530.1) and constructed corresponding gene targeting vectors. Gene targeting efficiency analysis in goat fibroblasts showed that the sgRNA were efficient in directing Cas9 to generate targeted indels in corresponding IGLλ genes with efficiencies ranging between 20 and 30%. We then targeted the IGLλ genes and generated a cloned IGLλ −/− fetus by SCNT (first round of cloning; G1) using single cell-derived IGLλ −/− fibroblast colonies as nuclear donors and established IGLλ −/− fetal fibroblast cell lines. Second, we established IGLλ −/− /HAC fibroblast colonies by transferring the isKcHACΔ, a HAC containing the entire unrearranged human immunoglobulin heavy-chain and kappa-chain sequences, into the IGLλ −/− fetal fibroblast cells via microcell-mediated chromosome transfer (MMCT; Matsushita et al. 2014 PLoS One 9, e90383). The resulting IGLλ −/− /HAC fibroblasts were used as nuclear donors for the production of IGLλ −/− /HAC goats by SCNT (second round of cloning; G2). A total of 311 one-cell stage G2 embryos were generated using 4 IGLλ −/− /HAC fetal fibroblast colonies and surgically transferred into 19 oestrus-synchronized recipients. Seven pregnancies were confirmed (7/19; 36.8%) with ultrasonography at Day 60±3 of gestation, and 1 pregnancy (1/7; 14.3%) developed to term, leading to the birth of a live and healthy kid. Genetic and serological characterisation of this Tc goat produced by the second round of SCNT is in progress.

Abstract P1-09-04: Activity of CT7001 an orally bio-available cyclin-dependent kinase 7 selective inhibitor in models of triple negative breast cancer

Triple-negative breast cancer (TNBC) is a highly aggressive and heterogeneous subtype of breast cancer that commonly exhibit poor prognosis and high relapse rates at early stages after conventional neoadjuvant chemotherapy. CDK7 inhibition has emerged as an 'Achilles heel' in TNBC via blocking transcriptional addiction to a defined cluster of genes (Wang et al 2015). CDK7 acts as a CDK-activating kinase controlling proliferation and as a transcriptional kinase phosphorylating RNA Polymerase II. Eukaryotic RNA polymerase II (Pol II) is a 12-subunit DNA-dependent RNA polymerase that is responsible for transcribing nuclear genes encoding messenger RNAs and several small nuclear RNAs (R Young 1991)

We have demonstrated that established cell-lines and patient derived tumour tissue (PDTT, explants established as models at low passage numbers that have not been grown in plastic or propagated as cell cultures) of TNBC are sensitive to a potent, selective and orally bioavailable CDK7 inhibitor CT7001 (ICEC0942). CT7001 produces a concentration-dependent inhibition of growth with GI50s &lt;1 micromolar across all TNBC cells tested to-date. The inhibition of proliferation was associated with an inhibition of c-MYC, Mcl-1 and phospho-Pol II as determined by Western Blot analysis. This demonstrates that CT7001 effectively controls transcriptional regulation and anti-apoptotic mechanisms in a diverse group of TNBC cellular models.

CT7001 was also evaluated in an in vivo orthotopic-PDX model of TNBC in nu/nu mice. Establishing PDX-xenograft tumour models from PDTT at low passage is believed to conserve original tumour characteristics such as heterogeneous histology, clinical biomolecular signature, malignant phenotypes and genotypes. Therefore, patient-derived tumour grafts are believed to offer relevant predictive insights into clinical outcomes when evaluating the efficacy of novel cancer therapies. Orally administered CT7001 monotherapy produced strong and sustained regression of the tumour that persisted during the dosing schedule and strong suppression was still maintained upon cessation of treatment. At doses that produced regression CT7001 was well tolerated with little effect on body weight loss (&lt;10%).

CT7001 is a potent, selective and orally bioavailable inhibitor of CDK7 that shows promise as a potential new treatment for TNBC.

References

Richard A. Young Annual Review of Biochemistry. 1991 60 (1): 689–715

Wang et al Cell. 2015 163(1):174-86.

Citation Format: Bahl AK, Einscow E, Leishman A, Sullivan E, Ali S, Coombes RC, Barrett AGM, Li B, Gallagher WM, Carragher NO, Patel T. Activity of CT7001 an orally bio-available cyclin-dependent kinase 7 selective inhibitor in models of triple negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-09-04.

28 Generation of Immunoglobulin Heavy Constant Mu (IGHM) Knockout Goats Using CRISPR/Cas9 and Somatic Cell Nuclear Transfer

Towards the goals of inactivating endogenous goat immunoglobulin (Ig) genes and producing fully human polyclonal antibodies in transchromosomal goats carrying a human artificial chromosome comprising the entire human Ig gene repertoire, we report here the successful generation of IgM heavy chain knockout (IGHM−/−) goats using CRISPR/Cas9 and somatic cell nuclear transfer (SCNT) techniques. Two single-guide RNAs (sgRNAs) were designed specific for exon 1 of the goat IGHM constant region (GenBank: EU182621.1). The gene-targeting vectors were constructed by using pX330 plasmid (Plasmid No. 42230, Addgene, Cambridge, MA, USA) and transfected into 2 × 105 goat fetal fibroblast cells. Gene-targeting efficiency of each targeting vector was determined by PCR-restriction fragment length polymorphism (RFLP) assay 3 days post-transfection. Our results showed that one of the sgRNAs, 5′-GAAAGGCGCTTGAGGAATGC-3′, was efficient in directing Cas9 to generate targeted cleavages in exon 1 of IGHM constant region, with a mutation efficiency of 20%. We established single cell-derived fetal fibroblast colonies by limiting dilution of the cells transfected with the targeting vector. Colony screening with the PCR-RFLP assay confirmed that we achieved targeted gene disruption in exon 1 in 11/49 (22.4%) of the colonies (7 colonies with biallelic and 4 with monoallelic gene disruption). Sanger sequencing analysis of genomic DNA isolated from cell colonies with biallelic mutations showed that typical nucleotide deletions and insertions (indels), caused by repairing double-strand DNA breaks during the error-prone non-homologous end joining (NHEJ) process, were generated at the targeting site of exon 1. One of the colonies harboring a 1-nucleotide (nt) deletion was used as nuclear donors for SCNT. A total of 102 1-cell-stage cloned embryos were generated and surgically transferred into 6 synchronized recipients. Three of the recipients (3/6, 50.0%) were confirmed pregnant by ultrasonography on Day 40 to 45 of gestation. Two pregnancies were sacrificed for IGHM−/− fetal fibroblast isolation and one pregnancy was allowed to go to term, which led to the birth of a live and seemingly healthy kid. This goat was reared conventionally and appeared healthy until 5 weeks of age when it was killed because of commensal virus infection. The PCR-RFLP assay and sequence analysis showed that this cloned goat carried a biallelic 1-nt deletion in exon 1 of IGHM, which was identical to the donor colony it was originated from. No lymphoid follicles were observed in lymph nodes and spleen by histology, and immunohistochemistry for B cells (CD20) and T cells (CD3) demonstrated a lack of B cells in lymph nodes and spleen but the presence of T cells, confirming that IGHM has been successfully knocked out.

Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity

OBJECTIVE

Develop a core outcome set of international consensus definitions for severe maternal morbidities.

DESIGN

Electronic Delphi study.

SETTING

International.

POPULATION

Eight expert panels.

METHODS

All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions.

MAIN OUTCOME MEASURES

Definitions with a rate of agreement of more than 70%.

RESULTS

The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions.

CONCLUSION

Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative.

TWEETABLE ABSTRACT

Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

Impact of psoriasis flare and remission on quality of life and work productivity: a real-world study in the USA

Although psoriasis patients often report a negative impact on health-related quality of life (HRQoL) and work productivity, less is known about how disease burden varies between periods of flare and remission. The aim of this study was tocompare HRQoL and work productivity by disease activity level. Data were extracted from Adelphi 2011/2013 Disease Specific Programmes, two real world surveys of US dermatologists and psoriasis patients. HRQoL was measured using the EuroQOL 5-Dimension Health Questionnaire (EQ-5D) and Dermatology Life Quality Index (DLQI). Work productivity was measured using the Work Productivity Activity index (WPAI). Three levels of disease activity were constructed based on physician reports: remission, active not flaring, active, and flaring. Multivariable regression analyses explored the relationship between disease activity, HRQoL and work productivity, controlling for differences in demographics and comorbidities. Out of 681 psoriasis patients 24% were in remission, 62% had active disease without flaring, and 15% experienced active disease and were currently flaring. Greater disease activity was associated with worse HRQoL. EQ-5D scores decreased with more active disease (remission vs. active not flaring vs. active and flaring: 0.93 vs. 0.90 vs. 0.82; p&lt;0.05), while DLQI scores increased (remission vs. active not flaring vs. active and flaring: 2.0 vs. 5.00 vs. 8.7; p&lt;0.05). WPAI scores increased with disease activity indicating increased productivity loss (remission vs. active not flaring vs. active and flaring: 5.9 vs. 14.8 vs. 26.9; p&lt;0.05). The same trends were confirmed by multivariable regression analyses.

Satisfaction with current psoriasis treatment: misalignment between physician and patient perceptions

Psoriasis patients often report dissatisfaction with treatment. However, the extent to which patients and their treating dermatologists are aligned regarding satisfaction with psoriasis therapy is largely unknown. This was explored using data derived from the Adelphi 2011/2013 Psoriasis Disease Specific Programmes, two real world surveys of US dermatologists and their patients. Physicians and patients independently reported their satisfaction with psoriasis control (satisfied, dissatisfied). Two levels of satisfaction alignment between physician and patient responses were constructed: aligned (same responses) and misaligned (different responses). In addition, dermatologists provided patient treatment history and disease/symptom severity whereas patients reported data on health-related quality of life (HRQoL), using the EuroQOL 5-Dimension Health Questionnaire (EQ-5D) and Dermatology Life Quality Index (DLQI), and work productivity using the Work Productivity Activity index (WPAI). Multivariate regressions were employed to examine the relationship between satisfaction alignment, overall disease and symptom severity, HRQoL, and work productivity controlling for differences in patient demographics and comorbidities.From 627 paired dermatologist and psoriasis patient records, 512 (81.7%) and 115 (18.3%) cases fell into the 'aligned' and 'misaligned' groups, respectively. Compared with patients in the aligned group, those in the misaligned group had more moderate to severe psoriasis (82.3% vs. 43.7%), moderate to severe itching (45.6% vs. 27.8%), pain (23.0% vs. 10.6%), and scaling (54.8% vs. 36.1%), and had lower current biologics use (27.0% vs. 42%) (all p&lt;0.05). The misaligned group was associated with reduced HRQoL (lower EQ-5D score: 0.86 vs. 0.91; higher DLQI score: 7.06 vs. 4.23) and greater work productivity loss (higher WPAI scores: 18.27 vs. 11.43) (all p&lt;0.05). Multivariate analyses confirmed these results (p&lt;0.05). Almost 1 in 5 patients were misaligned with their dermatologist's level of satisfaction with their psoriasis treatment; misalignment was associated with increased disease and symptom severity, reduced HRQoL, and reduced work productivity.

Patient satisfaction with current psoriasis treatment: a real-world study in the USA

Psoriasis patients often report dissatisfaction with treatment. However, it is less clear how the severity of key psoriasis symptoms (painful skin, itching, and scaling) as well as overall disease severity influence patient dissatisfaction levels. Using the Adelphi 2011/2013 Psoriasis Disease Specific Programmes, two "real world" surveys of US dermatologists and their patients, patient satisfaction was evaluated. Dermatologists provided data on disease characteristics, while patients indicated their satisfaction with existing treatment. Physician-reported severity (none, mild, moderate/severe) of psoriasis-related itching, pain, and scaling, overall disease severity (mild, moderate and severe) and therapy type were compared by patient satisfaction levels (satisfied vs. dissatisfied). Multivariate regressions examined the relationship between patient satisfaction, clinical symptoms, and psoriasis overall disease severity, controlling for differences in patient demographics and comorbidities. The sample comprised 633 psoriasis patients (56% male) with a mean age of 45. Overall, 18% of patients reported dissatisfaction with their psoriasis treatment. Dissatisfied patients were more likely to have moderate (65% vs. 40%) or severe (21% vs 3%) psoriasis compared to patients who were satisfied (both p<0.05). Dissatisfied patients were also more likely to have more severe pain (30% moderate-to-severe pain vs. 9%), more severe itching (61% moderate-to-severe itching vs. 25%), and more severe scaling (68% moderate-to-severe scaling vs. 33%) than satisfied patients (all p< 0.05). Multivariate analyses confirmed these results. Clinicians should be aware that some psoriasis patients, especially those with severe overall disease or symptoms, may be dissatisfied and are in need of better treatment.

Increased severity of itching, pain, and scaling in psoriasis patients is associated with increased disease severity, reduced quality of life, and reduced work productivity

BACKGROUND

Psoriasis patients report that this disease can impact on their health-related quality of life (HR-QoL) and work productivity. It is important to understand how this is influenced by the clinical characteristics of psoriasis such as symptom severity. Common symptoms include itching, pain, and scaling but the psychosocial impact these features have on patients is not well understood.

OBJECTIVE

To explore the impact of psoriasis symptoms (itching, pain, and scaling) on HR-QoL and work productivity.

METHOD

Data were extracted from the Adelphi 2011 and 2013 Psoriasis Disease Specific Programmes - two real world surveys of US dermatologists and their psoriasis patients.  HR-QoL was measured using the Dermatology Life Quality Index (DLQI) and EuroQOL 5-Dimension Health Questionnaire (EQ-5D). Work productivity loss was measured by the Work Productivity and Activity Impairment (WPAI) questionnaire. The impact of symptom severity (none, mild, moderate/severe) for itching, pain, and scaling on DLQI, EQ-5D, and WPAI scores were examined, controlling for differences in demographics and co-morbidities.

RESULTS

Patient mean age was 44 years and 55% were male. Moderate/severe itching, pain, and scaling were experienced by 33%, 13%, and 41% of patients, respectively. Controlling for differences in demographics and co-morbidities, increased symptom severity was associated with reduced HR-QoL. Accordingly, EQ-5D scores decreased with itching severity (moderate/severe vs. none: -0.07; 95% confidence interval [CI] =-0.09, -0.04), whereas DLQI scores increased (moderate/severe versus none: 4.9; CI = 3.9, 5.9) (both p&lt;0.05). WPAI scores increased with itching severity, indicating increased work productivity loss (moderate/severe versus none: 17.6, CI = 11.8, 23.5, p&lt;0.05). The same pattern was observed for pain and scaling.

CONCLUSIONS

Among the patients studied, increased severity of psoriasis-related itching, pain, and scaling was associated with reduced health-related QoL and work productivity.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Objectively measured physical activity and C-reactive protein: National Health and Nutrition Examination Survey 2003-2004

The association between physical activity (PA) and C-reactive protein (CRP) is inconsistent, with nearly all studies using self-report measures of PA. The purpose of this study was to examine the association between objectively measured PA and CRP in US adults and children. Adults (N=2912) and children (N=1643) with valid accelerometer data and CRP data were included in the analyses. Logistic regression analysis was used to assess the odds of meeting PA guidelines across CRP quartiles for children and among adults with low, average, and high CRP levels. For adults, after adjustments for age, gender, race, body mass index, smoking, diabetes, and high-density lipoprotein cholesterol (HDL-C), compared with those with low CRP levels, odds ratios were 0.59 (CI=0.45-0.77) and 0.46 (CI=0.28-0.76) for participants with average and high CRP levels, respectively. For children, after adjustments for age, gender, race, weight status, and HDL-C, compared with those in CRP quartile 1, odds ratios were 0.96 (CI=0.5-1.84), 1.23 (CI=0.71-2.12), and 0.79 (CI=0.33-1.88) for participants in quartiles 2, 3, and 4, respectively. Objectively measured PA is inversely associated with CRP in adults, with PA not related to CRP in children.

Alendronate for the treatment of pediatric osteogenesis imperfecta: a randomized placebo-controlled study

CONTEXT

Information on the use of oral bisphosphonate agents to treat pediatric osteogenesis imperfecta (OI) is limited.

OBJECTIVE

The objective of the investigation was to study the efficacy and safety of daily oral alendronate (ALN) in children with OI.

DESIGN AND PARTICIPANTS

We conducted a multicenter, double-blind, randomized, placebo-controlled study. One hundred thirty-nine children (aged 4-19 yr) with type I, III, or IV OI were randomized to either placebo (n = 30) or ALN (n = 109) for 2 yr. ALN doses were 5 mg/d in children less than 40 kg and 10 mg/d for those 40 kg and greater.

MAIN OUTCOME MEASURES

Spine areal bone mineral density (BMD) z-score, urinary N-telopeptide of collagen type I, extremity fracture incidence, vertebral area, iliac cortical width, bone pain, physical activity, and safety parameters were measured.

RESULTS

ALN increased spine areal BMD by 51% vs. a 12% increase with placebo (P < 0.001); the mean spine areal BMD z-score increased significantly from -4.6 to -3.3 (P < 0.001) with ALN, whereas the change in the placebo group (from -4.6 to -4.5) was insignificant. Urinary N-telopeptide of collagen type I decreased by 62% in the ALN-treated group, compared with 32% with placebo (P < 0.001). Long-bone fracture incidence, average midline vertebral height, iliac cortical width, bone pain, and physical activity were similar between groups. The incidences of clinical and laboratory adverse experiences were also similar between the treatment and placebo groups.

CONCLUSIONS

Oral ALN for 2 yr in pediatric patients with OI significantly decreased bone turnover and increased spine areal BMD but was not associated with improved fracture outcomes.

Critical illness with AH1N1v influenza in pregnancy: a comparison of two population-based cohorts

OBJECTIVE

To compare admissions to intensive care units (ICUs) with confirmed AH1N1v influenza in pregnancy in Australia, New Zealand and the UK.

DESIGN

National cohort studies.

SETTING

ICUs in Australia, New Zealand and the UK.

POPULATION

Fifty-nine women admitted to ICUs in Australia and New Zealand in June-August 2009, and 57 women admitted to ICUs in the UK in September 2009-January 2010.

METHODS

Comparison of cohort data.

MAIN OUTCOME MEASURES

Incidence of ICU admission, comparison of characteristics and outcomes.

RESULTS

There was a significantly higher ICU admission risk in Australia and New Zealand than in the UK (risk ratio 2.59, 95% CI 1.75-3.85). Indigenous women from Australia and women with Maori/Pacific Island backgrounds from New Zealand had the highest admission risk (29.7 admissions per 10 000 maternities, 95% CI 17.9-46.3). Women admitted in Australia and New Zealand were significantly more likely to have a pre-existing medical condition (51% versus 21%, P = 0.001), but were less likely to receive antiviral treatment (80% versus 93%, P = 0.038) than women admitted in the UK. Women admitted in the UK had a longer length of hospital stay (median 21 days, range 3-128 days) than women admitted in Australia and New Zealand (median 12 days, range 3-66 days), but there were no other differences in maternal or pregnancy outcomes.

CONCLUSIONS

The difference in admission risk may reflect a second phase effect from successful clinical and public health interventions, as well as differences in population characteristics between the countries. The overall severity of the AH1N1v influenza infection in pregnancy is evident, and emphasises the importance of an ongoing immunisation programme in pregnant women in both northern and southern hemispheres.