Infant neurodevelopment during the COVID-19 pandemic: Associations with maternal pandemic-related experiences, parenting stress, and self-efficacy

BACKGROUND

Although pandemic-related experiences have been linked to the psychological well-being of mothers, the effects of the COVID-19 pandemic on infant neurodevelopmental outcomes have not been sufficiently studied.

AIMS

To assess whether maternal COVID-19-related experiences (i.e., COVID-19-related health, risk, resource worries, and feelings of grief), parenting stress, and maternal self-efficacy are associated with infant neurodevelopment as measured by the Ages and Stages Questionnaire, Third Edition (ASQ-3) maternal report when infants were between 8 to 10 months of age. Furthermore, this study examined the moderating effect of maternal self-efficacy between maternal COVID-19-related experiences and infant neurodevelopment.

METHODS

This cross-sectional study included 122 women who were drawn from the Perinatal Experiences and COVID-19 Effects (PEACE) Study, with online surveys administered between November 2020 and August 2022.

RESULTS

After controlling for maternal anxiety and depression symptoms and demographic factors, hierarchical regression analysis indicated that parenting stress showed no effect on ASQ-3 scores. However, more adverse COVID-19-related experiences and higher levels of maternal self-efficacy were associated with better infant neurodevelopment. Moreover, there was a significant interaction effect between maternal self-efficacy and COVID-19-related experiences on infant neurodevelopment. For mothers with moderate to high levels of self-efficacy, more adverse COVID-19-related experiences were associated with better infant neurodevelopment. For mothers with low levels of self-efficacy, more adverse COVID-19-related experiences were associated with poorer developmental outcomes in infants.

CONCLUSIONS

Under adverse conditions, confidence in caregiving may afford more optimal infant neurodevelopment. Interventions aimed at fostering maternal self-efficacy and addressing specific stressors can be valuable in promoting positive developmental trajectories for infants born during the pandemic.

Postpartum experiences among individuals with suspected and confirmed prenatal generalized anxiety disorder during the COVID-19 pandemic: Implications for help-seeking

Prenatal generalized anxiety disorder (GAD) is a common and underdiagnosed condition with negative health consequences to both the pregnant individual and child. Here we studied the relationship between diagnosis and treatment status of GAD during pregnancy (no GAD diagnosis, suspected but not diagnosed, diagnosed but not treated, diagnosed and treated) during the COVID-19 pandemic and postpartum mental health outcomes, while considering the potential influence of individual psychological factors such as distress tolerance and resilience and the role of COVID-19-related health worries. In this sample of predominantly highly educated and white birthing individuals, one in five respondents experienced GAD during pregnancy and another one in six suspected GAD but was not diagnosed. Amongst those with a GAD diagnosis, 30% did not receive treatment. We found that those with a GAD diagnosis during pregnancy who did not receive treatment showed the highest levels of postpartum anxiety and depressive symptoms in the postpartum, even after controlling for covariates, and experienced the most COVID-19-related health worries. In comparison, individuals with a GAD diagnosis during pregnancy who received treatment experienced significantly lower anxiety symptom burden and depressive symptom burden, with a symptom burden similar to those without a confirmed or suspected diagnosis after controlling for individual psychological factors. We conclude that clinicians should strongly consider screening for and treating prenatal anxiety to prevent suboptimal postpartum mental health outcomes.

COVID-19-related health worries and generalized anxiety symptoms: Higher risks in perinatal women without a pre-existing generalized anxiety diagnosis

The perinatal period has been well-established as a time of vulnerability to anxiety, as has the COVID-19 pandemic. Perinatal women with a prior diagnosis of Generalized Anxiety Disorder (GAD) may be anticipated to be at particular risk for elevated symptom burden when facing the overlay of these stressors. This study examined whether pre-existing anxiety exacerbates COVID-19-related health worries on anxiety symptom severity among a sample of women who entered perinatal status during the COVID-19 pandemic. We assessed COVID-19-related health worries, past diagnosis of GAD, and current generalized anxiety symptoms cross-sectionally in 1,587 perinatal U.S. women during the COVID-19 pandemic (May 21, 2020 to June 24, 2021). Among perinatal women who reported high levels of COVID-19-related health worries, those with a pre-existing GAD diagnosis were 3.56 times more likely to score at clinically significant levels of generalized anxiety, while those without a pre-existing GAD diagnosis were 6.51 times more likely. COVID-19-related health worries posed a larger risk for elevated anxiety symptoms among those without a pre-existing diagnosis of GAD. Greater access to treatment and psychoeducation for such individuals may be warranted for individuals without a pre-existing mental health diagnosis.

COVID-19 Pandemic Experiences and Maternal Stress in Neonatal Intensive Care Units

COVID-19 compounds the already high levels of psychological distress experienced by NICU mothers. We aimed to describe the rates of NICU-related maternal stress during the COVID-19 pandemic and to determine how COVID-19 experiences correlate with high levels of stress experienced by NICU mothers. We conducted a cross-sectional analysis based on responses to a nationwide online survey to understand the relationship between COVID-19-related experiences and the stress experienced by mothers of infants admitted to U.S. NICUs (n = 108) during the pandemic. Results indicate that 61.9% of surveyed mothers reported experiencing high levels of stress on the Parental Stressor Scale: NICU. COVID-19-related grief was significantly associated with higher levels of maternal stress, as it related to seeing the baby’s appearance and behavior in the NICU and exposure to sights and sounds within the NICU environment. No significant associations were noted between parental stress and COVID-19-related health worries or worries about resources. Of note, our recruitment relied on convenience sampling, limiting the generalizability of study results. In conclusion, mothers who experience COVID-19-related grief appear to be more vulnerable to NICU-related stress. Prioritizing parent involvement and enhancing psychosocial support are essential strategies to mitigate the long-term consequences of heightened stress for NICU families.

A systematic review of mHealth application interventions for peripartum mood disorders: trends and evidence in academia and industry

In this review, we aim to summarize research findings and marketplace apps for women with perinatal mood disorders with the goal of informing clinicians and patients about current risks and benefits, as well as proposing clinical implementation advice and a harmonized agenda for both academic and industry advancement in this space. Multiple searches were run of academic databases in 2018-2020, examining literature on mobile apps for peripartum mental health. Multiple searches were also run of the iOS and Android app stores in 2019 and 2020, looking at apps for peripartum mental health. Results were compared within the academic dataset as well within the commercial app dataset; the two datasets were also examined for overlap. The academic search results were notable for small sample sizes and heterogeneous endpoints. The app store search results were notable for apps of generally poor quality (as assessed by a modified Silberg scale). Very few of the mHealth interventions studied in the academic literature were available in the app store; very few of the apps from the commercial stores were supported by academic literature. The disconnect between academically developed apps and commercially available apps highlights the need for better collaboration between academia and industry. More collaboration between the two approaches may benefit both app developers and patients in this demographic moving forwards. Additionally, we present a set of practice guidelines for mHealth in perinatal psychiatry based on the trends identified in this review.

Abstract P4-10-02: Validation of a clinical informatics system for online multidisciplinary expert opinions: Mapping treatment recommendations to the NCCN resource-Stratified framework

Background: Most cancer patients in Low and Middle Income Countries (LMIC) cannot afford effective, expensive, evidence based therapies. Therefore, oncologists must tailor treatment plans to individual resource constraints. To support this, NCCN has created a Resource-Stratified Framework® (NCCN-RSF), which is an evidence-based four-tier prioritization scheme. Further, only a fraction of patients in LMIC have ready access to oncologists. In India, there are only ˜1600 oncologists for 1.8 million patients. To bridge this gap, Navya's clinical informatics based mobile ExpertApp combines learning from evidence, prior tumor board decisions, patient resource constraints, and quick review from TMC NCG oncologists to recommend tailored treatment plans to patients via an online expert opinion service. 11865 patients in 22 LMIC have reached out to receive an online expert opinion through Navya (ASCO 2017). This study maps Navya to NCCN-RSF as an evidence-based index for resource-sensitive treatment selection.

Methods: All breast cancer patients who received an online expert opinion from TMC NCG Navya between July 1st 2014 and April 30th 2017 were included. Navya systematically gathered information on patient resource constraints (such as affordability for Trastuzumab). Navya recommendations (breast and nodal surgery, radiation site and fractionation, drug and dose density etc.) were mapped to NCCN-RSF resource tiers (Basic, Core, Enhanced, Parent guideline). Reasons were categorized for Navya recommendations not present in NCCN-RSF.

Results: 616 patients (36.3% metastatic), mostly from India, received 1203 recommendations. At the specific treatment protocol level, 88.3% of Navya recommendations mapped with at least one NCCN-RSF resource tier (Table 1). 78.5% mapped to the Enhanced tier. Only 8.6% of recommendations mapped to Parent guidelines, and did not require tailoring for resource constraints. Fewer than 2% recommendations mapped to Core and none to Basic. 11.7% recommendations were not present in NCCN-RSF, for minor reasons such as substitution of a drug within the same class (35.8%) (e.g., Epirubicin for Adriamycin), dose dense protocols (14.3%) (e.g., 3 weekly Paclitaxel vs weekly Paclitaxel), and recommending Trastuzumab for less than a year for patients unable to afford year long therapy (14.3%), currently not included in NCCN-RSF.

Table 1- Mapping Navya to NCCN RSFNCCN RSF TiersHIGH LEVEL: Multimodality treatment and sequencing (1203)INTERMEDIATE: Within modality treatment categories (1188)GRANULAR: Specific treatment protocols (1140)E.g.Neoadjuvant vs Adjuvant ChemoAnthracycline vs TaxaneHypofractionation vs Standard XRTAt least one Tier98.8%±0.696%±1.188.3%±2Enhanced94.4%±1.391%±1.778.5%±2.7Core1.9%±5.61.2%±5.71.2%±5.8Parent NCCN2.4%±5.63.8%±5.68.6%±5.5

Conclusion: Navya's treatment recommendations are sensitive to resource constraints and map to peer reviewed and evidence based NCCN RSF, primarily at the Enhanced tier. Navya's clinical informatics based online service scales access to resource constrained treatment selection for large numbers of patients in LMIC without easy access to oncologists.

Citation Format: Badwe RA, Gupta S, Feldman N, Pramesh CS, Ramarajan N, Srivastava G, Nair N, Anderson BO. Validation of a clinical informatics system for online multidisciplinary expert opinions: Mapping treatment recommendations to the NCCN resource-Stratified framework [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 P4-10-02.

Lung disease severity in idiopathic pulmonary fibrosis is more strongly associated with impedance measures of bolus reflux than pH parameters of acid reflux alone

BACKGROUND

Gastroesophageal reflux (GER) has been associated with idiopathic pulmonary fibrosis (IPF). Pathogenesis may be related to chronic micro-aspiration. We aimed to assess objective measures of GER on multichannel intraluminal impedance and pH study (MII-pH) and their relationship with pulmonary function testing (PFT) results, and to compare the performance of pH/acid reflux parameters vs corresponding MII/bolus parameters in predicting pulmonary dysfunction in IPF.

METHODS

This was a retrospective cohort study of IPF patients undergoing prelung transplant evaluation with MII-pH off acid suppression, and having received PFT within 3 months. Patients with prior fundoplication were excluded. Severe pulmonary dysfunction was defined using diffusion capacity of the lung for carbon monoxide (DLCO) ≤40%. Six pH/acid reflux parameters with corresponding MII/bolus reflux measures were specified a priori. Multivariate analyses were applied using forward stepwise logistic regression. Predictive value of each parameter for severe pulmonary dysfunction was calculated by area-under-the-receiver-operating-characteristic-curve or c-statistic.

KEY RESULTS

Forty-five subjects (67% M, age 59, 15 mild-moderate vs 30 severe) met criteria for inclusion. Patient demographics and clinical characteristics were similar between pulmonary dysfunction groups. Abnormal total reflux episodes and prolonged bolus clearance time were significantly associated with pulmonary dysfunction severity on univariate and multivariate analyses. No pH parameters were significant. The c-statistic of each pH parameter was lower than its MII counterpart in predicting pulmonary dysfunction.

CONCLUSIONS & INFERENCES

MII/bolus reflux, but not pH/acid reflux, was associated with pulmonary dysfunction in prelung transplant patients with IPF. MII-pH may be more valuable than pH testing alone in characterizing GER in IPF.

Abstract P1-14-01: Building an experience engine to make cancer treatment decisions using machine learning

Introduction: Experts at tertiary care centers provide solutions to complex cases not addressed by high quality evidence. They intuitively retrieve patterns from years of experience to make treatment decisions. Short of personal consultations, there is no way to access this vast “experience database.” Experience Engine (XE) is a machine learning solution to structure experiential knowledge relevant for decision making, derive a similarity metric for patients who have received similar treatments, and predict treatment decisions that experts are likely to recommend.

Methods: 277 patient histories relating to 743 breast cancer tumor board decisions at two tertiary care centers were abstracted as the training set for machine learning. 161 distinct histories relating to 496 decisions for a separate expert opinion service at one of the centers was the holdout test set. Data was structured into 690 features based on a novel ontology designed specifically for breast cancer decision making.

To uncover nonlinear similarities, (for example, treatments for younger patients with multiple comorbidities and elderly patients may be similar), treatment decisions were grouped by timing and modality into 13 groups, such as primary surgery, 1st line palliative chemotherapy, etc.

Similarity metric was derived using machine learning on the training set. The target for prediction was the specific treatment decision i.e. TAC or another adjuvant regimen. The primary endpoint was percent accuracy of agreement between XE's predicted decision and experts' actual decision in the holdout test set. Multiple similarity distance metrics including Bhattacharya, Eskin, Goodall, etc., and multiclass classification algorithms such as Extreme Gradient Boosted Trees, Support Vector Machines, etc., were systematically evaluated to arrive at the algorithms that best fit each treatment group.

Results: The winning XE algorithms were 71% to 89% accurate for the various treatment groups, in predicting the actual treatment decisions recommended by the experts. The most frequent treatments recommended across all groups were standard evidence based therapies, as are often recommended by experts. For instance, when XE recommended standard adjuvant therapies for Her2- patients, it was 88% to 97% accurate. When XE recommended nonstandard therapies for the same treatment group, it was 72% to 90% accurate, related to larger number of nonstandard therapies within each treatment group and smaller samples of patients who underwent each type of nonstandard therapy. XE learned to weigh features relating to comorbidities and toxicities when recommending nonstandard therapies.

Conclusion: Machine learning on a structured database of past treatment decisions made by experts, can yield a predicted treatment decision that an expert is likely to recommend for a new patient. By including complex decisions that consider toxicities and morbidities, a rich source of knowledge can be created. Despite the limited dataset, XE learned features that experts strongly consider when making decisions. XE has the potential to analyze variations in decision making at expert practices, assess when to recommend nonstandard therapies, and serve as a training tool for new oncologists to make expert grade treatment decisions.

Citation Format: Ramarajan N, Gupta S, Perry P, Srivastava G, Kumbla A, Miller J, Feldman N, Nair N, Badwe RA. Building an experience engine to make cancer treatment decisions using machine learning [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-14-01.

First- and second-trimester maternal serum markers of pre-eclampsia in twin pregnancy

OBJECTIVE

To evaluate the distribution of first- and second-trimester maternal serum markers in twin pregnancy with and without pre-eclampsia.

METHODS

One-hundred and forty-four twin and 109 unaffected singleton pregnancies were recruited from the same institution. First- and second-trimester maternal blood samples were stored and measured retrospectively for serum placental growth factor (PlGF), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP). All had measurement of first-trimester serum markers, and 167 (66%) had second-trimester tests. Values were expressed in multiples of the gestation-specific median (MoMs) in singletons, adjusted for maternal weight, as appropriate.

RESULTS

Pre-eclampsia was diagnosed in 12 (9.0%) twin pregnancies of 133 continuing beyond 22 weeks. In unaffected twin pregnancies, all serum markers were statistically significantly increased (P < 0.0001), consistent with a doubling of concentration. Among twin pregnancies, those with pre-eclampsia had a significantly reduced median PlGF compared with surviving unaffected twin pregnancies (0.96 MoM vs 1.46 MoM; P < 0.0002, two-tailed), whilst median PAPP-A, which is known to be reduced in affected singleton pregnancies, was increased (3.91 MoM vs 2.43 MoM; P < 0.0005, two-tailed). The levels of free β-hCG (P < 0.02) and AFP (P < 0.05) were also significantly raised, but to a lesser extent than was the level of PAPP-A. Using a logistic regression algorithm based on first- and second-trimester PlGF and PAPP-A, together with previously published uterine artery Doppler and mean arterial pressure measurements in the same series, the predicted pre-eclampsia detection rate was 65% for a 10% false-positive rate.

CONCLUSIONS

In twin pregnancy, the predicted detection rate of pre-eclampsia using first- and second-trimester maternal serum and biophysical markers is good. In contrast to singleton pregnancy, PAPP-A levels are raised in the first trimester of twin pregnancies destined to develop pre-eclampsia and therefore a different prediction algorithm is needed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Increased proximal acid reflux is associated with early readmission following lung transplantation

BACKGROUND

Gastroesophageal reflux disease has been associated with poor outcomes following lung transplantation. However, the association between pretransplant reflux and post-transplant readmission, an indicator of early clinical outcome, has not been previously assessed.

METHODS

This was a retrospective cohort study of lung transplant recipients undergoing pretransplant multichannel intraluminal impedance and pH (MII-pH) study off acid suppression at a tertiary care center since 2007. Subjects with pretransplant fundoplication were excluded. Time to readmission was defined as duration from post-transplant discharge to next hospital admission for any reason. Subgroup analysis was performed to exclude elective readmissions. Time-to-event analysis was performed using Cox proportional hazards model, with appropriate censoring.

KEY RESULTS

Forty-three subjects (60% men, mean age: 57, median follow-up: 1.7 years) met inclusion criteria for the study. Patient demographics and pretransplant cardiopulmonary function were similar between readmission cohorts. Time to all-cause readmission was associated with increased distal acid episodes (HR: 3.15, p = 0.04) and proximal acid episodes (HR: 3.61, p = 0.008) on impedance, increased acid exposure on pH (HR: 2.22, p = 0.04), and elevated Demeester score (HR: 2.26, p = 0.03). When elective readmissions were excluded, early readmission remained significantly associated with increased proximal acid reflux episodes (HR: 2.49, p = 0.04). All findings were confirmed on Kaplan-Meier analysis.

CONCLUSIONS & INFERENCES

Elevated proximal acid reflux on pretransplant MII-pH testing was associated with early readmission following lung transplantation, even after excluding elective readmissions. Exposure to severe acid reflux has measurable effects on early postoperative outcomes such as readmission, and aggressive early antireflux therapy should be considered.

Idiopathic pulmonary fibrosis is associated with increased impedance measures of reflux compared to non-fibrotic disease among pre-lung transplant patients

BACKGROUND

Gastroesophageal reflux (GER) has been associated with idiopathic pulmonary fibrosis (IPF), although the mechanism remains unclear. Gastroesophageal reflux/microaspiration may lead to lung fibrosis, while increased pulmonary workload may also worsen GER. Comparing the GER profile of IPF patients to chronic obstructive pulmonary disease (COPD) patients with similar lung function may help delineate the role of GER in IPF pathogenesis.

METHODS

This was a retrospective cohort study of IPF and COPD patients undergoing pre-lung transplant multichannel intraluminal impedance and pH study (MII-pH) off acid suppression at a tertiary center in 2008-2014. Patients with prior fundoplication were excluded. Baseline demographics, pulmonary function test, and MII-pH results were recorded. Univariate analyses were performed using Fisher's exact (binary variables) and Student's t (continuous variables) tests. Logistic regression was performed to adjust for potential confounders.

KEY RESULTS

A total of 90 subjects (54 IPF, 36 COPD) met inclusion criteria. Compared to COPD, IPF patients had increased total reflux episodes (65.9 vs 46.1, p = 0.02), proximal reflux episodes (30.3 vs 20.3, p = 0.04), and prevalence of abnormal total reflux episodes (38.9% vs 16.7%, p = 0.02). On multivariate analyses, abnormal total reflux episodes (OR: 4.9, p = 0.05) and bolus reflux exposure time (OR: 4, p = 0.04) remained significantly associated with IPF.

CONCLUSIONS & INFERENCES

Abnormal reflux was significantly more prevalent among IPF patients after controlling for lung disease severity. Gastroesophageal reflux/microaspiration likely plays a role in fibrosis in IPF. A significant portion of IPF patients had increased non-acid reflux. Therapies aiming to prevent reflux of gastric contents may be more beneficial than antisecretory medications alone in these patients.

Idiopathic pulmonary fibrosis is associated with increased impedance measures of reflux compared to non-fibrotic disease among pre-lung transplant patients

BACKGROUND

Gastroesophageal reflux (GER) has been associated with idiopathic pulmonary fibrosis (IPF), although the mechanism remains unclear. Gastroesophageal reflux/microaspiration may lead to lung fibrosis, while increased pulmonary workload may also worsen GER. Comparing the GER profile of IPF patients to chronic obstructive pulmonary disease (COPD) patients with similar lung function may help delineate the role of GER in IPF pathogenesis.

METHODS

This was a retrospective cohort study of IPF and COPD patients undergoing pre-lung transplant multichannel intraluminal impedance and pH study (MII-pH) off acid suppression at a tertiary center in 2008-2014. Patients with prior fundoplication were excluded. Baseline demographics, pulmonary function test, and MII-pH results were recorded. Univariate analyses were performed using Fisher's exact (binary variables) and Student's t (continuous variables) tests. Logistic regression was performed to adjust for potential confounders.

KEY RESULTS

A total of 90 subjects (54 IPF, 36 COPD) met inclusion criteria. Compared to COPD, IPF patients had increased total reflux episodes (65.9 vs 46.1, p = 0.02), proximal reflux episodes (30.3 vs 20.3, p = 0.04), and prevalence of abnormal total reflux episodes (38.9% vs 16.7%, p = 0.02). On multivariate analyses, abnormal total reflux episodes (OR: 4.9, p = 0.05) and bolus reflux exposure time (OR: 4, p = 0.04) remained significantly associated with IPF.

CONCLUSIONS & INFERENCES

Abnormal reflux was significantly more prevalent among IPF patients after controlling for lung disease severity. Gastroesophageal reflux/microaspiration likely plays a role in fibrosis in IPF. A significant portion of IPF patients had increased non-acid reflux. Therapies aiming to prevent reflux of gastric contents may be more beneficial than antisecretory medications alone in these patients.

P5-19-08: Pooled Analysis of Individual Patient Data from Capecitabine Monotherapy Clinical Trials in Anthracycline-/Taxane-Pretreated Locally Advanced or Metastatic Breast Cancer (LA/MBC)

Background

Capecitabine (C) has shown efficacy as monotherapy in anthracycline (A)-/taxane (T)-pretreated LA/MBC in phase II/III trials. Since its approval, the treatment landscape in MBC has evolved, and C has served as the combination partner and/or active comparator in trials of novel agents in pretreated MBC. This pooled analysis of clinical trial data, spanning a 12-yr period, assessed the efficacy and safety of C across treatment lines and the impact of disease characteristics on clinical outcomes with C.

Methods: Individual patient (pt) data were pooled from 7 clinical trials conducted by Roche/GNE from Feb 1996-Jun 2008 where C monotherapy was the test/control regimen for pts with LA/MBC with/without prior A/T therapy. Analyses were performed on an ITT basis. Univariate and multivariate regression analyses assessed the impact of pt/disease characteristics and prior therapy on outcomes.

Results: Data from 805 pts enrolled to intermittent C monotherapy were analyzed: 268 in the 1st-line metastatic setting; 537 in the ≥2nd-line metastatic setting (table).

An association between thyroid disease and breast cancer

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Background: Anecdotal studies and isolated case reports have observed an association of thyroid disease and breast cancer. This purported association remains controversial. We describe a retrospective case-control study on the prevalence of breast cancer in patients with abnormal thyroid function studies. Age-matched subjects served as controls. Methods: We reviewed 6211 cases of abnormal TSH values between 1/04 and 12/05 and determined the number of cases with breast cancer. We compared those data to 3,151 control subjects with normal TSH seen during the same period. We excluded patients with thyroid cancer from the total number of malignancies in both groups because abnormal TSH would be expected to result from its treatment. We also reviewed the ER, PR, her 2 neu status and free thyroxine of patients with breast cancers. Results: Breast cancer rate of 36% of all cancers (37/102) in the abnormal TSH group was significantly higher than that of 18% (14/77) in the normal TSH group. (p = 0.012). Breast cancers in the study group with abnormal thyroid function were more frequently hormone receptor positive (74% vs. 67%) and her 2 neu negative (67% vs. 50%). Conclusions: The data suggest that there is an increased rate of breast cancer in patients with abnormal thyroid function. The trend of hormone receptor positive disease in the abnormal TSH group suggests that the IGF receptor may play an important role in the relationship between thyroid disease and breast cancer. The IGF receptor may be a potential target for therapeutic drug development for breast cancer prevention and management. Further studies are warranted.

No significant financial relationships to disclose.

[Nutritional status assessment in leprous hospitalized patients in Argentina]

INTRODUCTION

Leprosy is a regional problem of public health in the Argentine Republic. It has seen a continuous decrease of the prevalence in the last 10 years, with value is about 0.17/10000 citizen and the detection rate is constant about 0.10/10000 citizen. Even the death rate is low, its importance is given for the physicals, socials, permanents and the progressive disabilities that its produce if there no early diagnostic and a regular and complete treatment. The Dr. Baldomero Sommer National Hospital, that give a complete assistance to the leprosy patients either to the pavilion patients or the ill patients that help oneselves and live in houses with their families and where it is given food assistance to promote and increase their quality of life.

OBJECTIVES

Evaluate The nutritional state of the ill patients that help oneselves and live in houses with their families. Analyze the caloric and proteic brought by the institution.

MATERIAL AND METHODS

It is a transversal and descriptive study. We made a nutritional evaluation of the patients that live in each of the 4 suburb of the hospital, whom has been previously appointed by the coordinator of the zone, with the porpoise of identify the nutritional state of each one of the patients, quantify the nutritional risk, and indicate, adequate and monitories the nutritional support. The diagnostic was realized by the dietician through: anthropometric parameters (weight, height and body mass index), biochemical parameters, according to the clinical history: albumin, cholesterol, urea, hematocrito and associated illness.

RESULTS

We evaluated 219 patients of 246, with a middle age of 56.4 years, 62.2% males and 57.8% females. We detected that obesity was the nutritional disorder with mayor prevalence in these population (74.3%) and with mayor incidence in the moderate obesity in males and mayor incidence in severe obesity in females. The prevalence of malnourishment was 3.6% and well-nourished was 23.7%, 27 of the patients (10.9%) did not go to the nutritional evaluation. The 2.8% of the patients did not have an actual laboratory for more than 2 years. In the clinical histories, we found that the dosage of albumin in an average of 4.2 g/dl, and the 2.8% of the patients did not have any value of albumin. The values of hematocrito and urea determinate an adequate brought of proteins in the evaluated population. Inside the nutritional diagnostic we considerate the search of diabetes (present ion the 9.7% of the patients), dislipemia (present ion the 32.8% of the patients, taken a level of 200 mg / dl of cholesterol), chronic renal deficiency (present in the 9.3% of the patients), and arterial hypertension (present in the 33.6% of the patients).

CONCLUSIONS

Exist a high prevalence of moderate-severe obesity in the studied population that have no coincidence with the universal literature. These data shows the necessity to adequate the caloric and proteic brought to the patients. The majority of the patients presented Dislipemia and or diabetes and or arterial hypertension. Promote the development of educational programs to better the nutritional state of the risk population, better the quality of life and reduce cardiovascular risks, using an international model that include strategies for the following of a health diet and an increase of physical activity.

Characterization of a novel founder rearrangement mutation of BRCA1 in high-risk Hispanic families

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Background: Large rearrangements are estimated to account for 5–10% of all mutations in BRCA1 and BRCA2. Prevalent founder rearrangement mutations have been described in European populations. We sought to identify rearrangements in the BRCA genes in a cohort of Hispanic patients. Methods: We identified 34 deleterious BRCA mutations via full sequence analysis among 110 unrelated high-risk Hispanic families enrolled in an IRB approved registry who underwent cancer risk assessment (CEBP 2005;14:1–6). DNA from 67 of 76 patients without an identifiable mutation was subjected to multiplexed quantitative differential PCR (MQDP, per B. Erickson and T. Scholl, Myriad Genetics Laboratory) for detection of large rearrangements. An apparent deletion of BRCA1 exons 9–12, indicated by a 50% loss of signal was identified by MQDP in 3 unrelated families (ASHG, 2005). Long range PCR resulted in the generation of a 2.7kb product in these samples, consistent with a deletion event of 15.1kb. This putative mutation was further characterized by cloning and sequencing the breakpoint in all 3 families. RNA splicing was evaluated by sequencing RT-PCR products from lymphoblastoid cell line RNA for each family. Results: Sequence analysis identified the breakpoint within Alu elements in introns 8 and 12, and all 3 unrelated families shared the same breakpoint. Analysis of cDNA demonstrated direct splicing of exons 8–13 predicting a frameshift mutation and premature truncation of the BRCA1 protein, thus confirming the deleterious nature of this mutation. Conclusion: We identified the same novel large deletion in three unrelated families of Mexican ancestry, suggesting potential founder effect. The frequency was 2.7% of the 110 high-risk Hispanic families screened for BRCA mutations, bringing the overall prevalence of deleterious mutations to 33.6%(37/110) in this cohort. This BRCA1 rearrangement may account for a substantial proportion of high-risk Hispanic families, and should be included in all subsequent studies of this ethnic group.

No significant financial relationships to disclose.

Codon 72 polymorphism of p53 in Israeli Jewish cervical cancer patients and healthy women

Recently it has been found that the presence of homozygous arginine polymorphism at codon 72 of p53, represents a significant risk factor in the development of HPV-associated cervical cancer. The incidence of cervical carcinoma is persistently very low in Israeli Jewish women for unknown reasons. The incidence among those of North African origin is relatively higher. The aim of the present study was to assess the frequency distribution of the p53 homozygous arginine polymorphism in cervical cancer patients and in a population sample of healthy Israeli Jewish women in order to determine whether the incidence pattern among them is genetically based. The cases consisted of 23 Israeli Jewish patients with histologically confirmed squamous cell carcinoma of the cervix. A group of 162 randomly chosen Israeli Jewish healthy participants, considered to represent the general population, comprised the controls. The germline p53 polymorphism at codon 72 was determined by PCR in DNA obtained from a blood sample taken from each subject. Homozygous arginine was found in 34.8% of cases and in only 14.8% of controls. This difference was statistically significant (P = 0.01). The frequency of homozygous arginine polymorphism in controls was lower than in any other population hitherto reported. It was significantly more common among those of North African than among those of other origin (30.3% vs. 10.8%; P < 0.01). It may be assumed that the low incidence of cervical cancer in Israeli Jewish women and the differences between the ethnic groups may be related to the frequency pattern of the homozygous arginine p53 polymorphism

Codon 72 polymorphism of p53 in Israeli Jewish cervical cancer patients and healthy women

Recently it has been found that the presence of homozygous arginine polymorphism at codon 72 of p53, represents a significant risk factor in the development of HPV-associated cervical cancer. The incidence of cervical carcinoma is persistently very low in Israeli Jewish women for unknown reasons. The incidence among those of North African origin is relatively higher. The aim of the present study was to assess the frequency distribution of the p53 homozygous arginine polymorphism in cervical cancer patients and in a population sample of healthy Israeli Jewish women in order to determine whether the incidence pattern among them is genetically based. The cases consisted of 23 Israeli Jewish patients with histologically confirmed squamous cell carcinoma of the cervix. A group of 162 randomly chosen Israeli Jewish healthy participants, considered to represent the general population, comprised the controls. The germline p53 polymorphism at codon 72 was determined by PCR in DNA obtained from a blood sample taken from each subject. Homozygous arginine was found in 34.8% of cases and in only 14.8% of controls. This difference was statistically significant (P = 0.01). The frequency of homozygous arginine polymorphism in controls was lower than in any other population hitherto reported. It was significantly more common among those of North African than among those of other origin (30.3% vs. 10.8%; P < 0.01). It may be assumed that the low incidence of cervical cancer in Israeli Jewish women and the differences between the ethnic groups may be related to the frequency pattern of the homozygous arginine p53 polymorphism

Enrichment of an Israeli ethnic food with fibres and their effects on the glycaemic and insulinaemic responses in subjects with non-insulin-dependent diabetes mellitus

The effects of various sources of dietary fibre on the high glycaemic index of an Israeli ethnic food, melawach, were investigated in subjects with non-insulin-dependent diabetes mellitus (NIDDM). Locust-bean (Ceratonia siliqua) gum significantly decreased the glucose response to, and glycaemic index of, melawach in these diabetic subjects (P < 0.05). It also tended to decrease their insulinaemic response and insulinaemic index, but differences were not significant. Dietary fibre from lupin (Lupinus albus) and insoluble maize-cob fibre did not affect glucose and insulin levels in NIDDM volunteers. Subjects with a BMI < 30 kg/m2 exhibited similar glucose, but not insulin, responses to fibre. Locust-bean gum had no significant effect on glycaemic response in NIDDM subjects with a BMI > 30 kg/m2, whereas insulinaemic response decreased. The results indicate that foods containing the same nutrients in almost the same amounts, but differing in added dietary fibre, lead to different physiological responses in diabetic subjects. Furthermore, insulin response should be considered when fibre is incorporated into the diabetic's diet.

Postcontrast MRI of cranial meninges: leptomeningitis versus pachymeningitis

OBJECTIVE

Our goal was to characterize the patterns of meningeal enhancement in postcontrast MR images and correlate these patterns with the clinical disorders.

MATERIALS AND METHODS

The MR scans, medical records, and laboratory findings of 83 patients, whose postcontrast MR studies of the head demonstrated meningeal enhancement, were reviewed retrospectively. The patterns of enhancement of the different layers of the meninges were divided into two types: leptomeningeal (pia and arachnoid), when enhancement of the meninges followed the convolutions of the gyri and/or involved the meninges around the basal cisterns; and pachymeningeal (dura), when the enhancement was thick and linear or nodular along the inner surface of the calvarium, falx, or tentorium without extension into the cortical gyri or basal cistern involvement. Enhancement around the basal cistern was considered leptomeningeal, since the dura-arachnoid is widely separated from the pia-arachnoid in this region. Further, the meningeal enhancement was divided into five etiologic subgroups, i.e., carcinomatous, infectious, inflammatory, reactive, and chemical. The medical history, clinical presentation, and findings on CSF analysis were used to distinguish infectious from carcinomatous meningitis. Meningeal enhancement due to surgery, shunt, or trauma was considered reactive, while ruptured cysts (dermoid or cysticercoid) or intrathecal chemotherapy were classified as chemical meningitis. Meningitis secondary to involvement by collagen vascular disease or sarcoidosis was considered to be inflammatory.

RESULTS

Thirty of the 83 subjects had carcinomatous, 28 infectious, 14 reactive, 8 chemical, and 3 inflammatory etiology for meningitis. Twenty-five cases (83%) of the carcinomatous, 14 (100%) of the reactive, 3 (100%) of the inflammatory, and 1 (12%) of the chemical meningitis subgroups demonstrated pachymeningeal enhancement, while 28 cases (100%) of the infectious meningitis and 7 (78%) of the chemical meningitis subgroups had leptomeningeal enhancement. Only five cases (17%) of the carcinomatous meningitis subgroup showed leptomeningeal enhancement. Four of these five cases were as a result of direct spread of intraparenchymal tumors or through perineural extension, rather than hematogenous involvement. Only one patient with carcinomatous meningitis demonstrated leptomeningeal enhancement without clear intraparenchymal lesion.

CONCLUSION

The recognition of various patterns of meningeal enhancement (leptomeningitis versus pachymeningitis) may help in differentiating between infectious and carcinomatous meningitis. This study demonstrated that infectious meningitis presents mostly as leptomeningitis, while carcinomatous meningitis presents as pachymeningitis.

The incidence of significant fetomaternal hemorrhage in patients undergoing cesarean section

To determine the incidence of fetomaternal hemorrhage in patients undergoing cesarean section, Kleihauer-Betke tests were performed in the immediate postoperative period on 199 parturients. Some degree of hemorrhage was detected in 18.5% of patients, with 2.5% demonstrating greater than 30 ml of fetal blood. Comparison of groups on the basis of indication for cesarean delivery revealed no difference in rates of fetal hemorrhage. Because patients with greater than 30 ml of fetal blood would not be adequately protected from Rh sensitization by the standard 300 micrograms dose of Rh immune globulin, we recommend screening all Rh-negative patients undergoing cesarean section for the presence of significant fetomaternal hemorrhage.

A false-positive indium-111 labeled leukocyte scintigram in a patient with a painful hip prosthesis

A Tronzo hip prosthesis is designed to elicit an inflammatory reaction in order to promote prosthesis stability. A three-phased bone scan and Ga-67 imaging in conjunction with physical examination and laboratory findings failed to demonstrate evidence for osteomyelitis in a patient with a painful hip prosthesis, in whom images obtained with In-111-labeled leukocytes were positive. This observation demonstrated that the interpretation of the latter technique in demonstrating inflammation can cause a false impression of an infectious process.

Visualization of the uterus on evaluation of transplanted kidneys

A vascular blush was noted in the pelvis during flow studies in two women with kidney transplants. The vascular structure was noted to be due to the uterus. In one patient, the activity in the area of the uterus could have been mistaken for excretion of agent into the bladder.

Some chemical characteristics of dimethylsuberimidate and its effect on sarcoplasmic reticulum vesicles

Sarcoplasmic reticulum vesicles treated with dimethylsuberimidate lose the capacity for ATP-promoted Ca2+ accumulation and show other properties indicative of leaky vesicles. As an aid to assessing whether this effect was caused by cross-linking or by hydrolysis products, characteristics of dimethylsuberimidate hydrolysis under incubation conditions used were measured. At pH 7.0, 25 DEGREES C, dimethylsuberimidate is hydrolyzed with an apparent first order rate constant of 0.016 min-1, to give dimethylsuberate as the principal product. The effect on ATP-promoted Ca2+ accululation was shown to be caused by partially and fully hydrolyzed products of the diimido ester, and not to cross-linking of membrane components.