The Relationship Between Uterine Activity, Oxytocin Dosing, Labor Progress, and Mode of Birth in Nulliparas with Obesity: Minimal Usefulness of Montevideo Unit Measurement

BACKGROUND

Maternal obesity and cesarean birth disproportionately affect Black parturients; thus, prevention of cesarean birth is a key modifiable factor to improve pregnancy outcomes and reduce disparities. The primary driver of unplanned cesarean birth among people with higher body mass index is prolonged labor duration. However, strategies to optimize outcomes in these situations have not been established. We aimed to evaluate the influence of oxytocin augmentation on uterine activity and labor progression in nulliparas with obesity.

METHODS

This secondary analysis involved nulliparas with obesity (BMI ≥30 kg/m2) who had spontaneous labor onset followed by oxytocin augmentation and an intrauterine pressure catheter. Using Linear Mixed Models, we evaluated relationships between uterine activity measured in Montevideo units (MVU), oxytocin dose, and rate of cervical dilation normalized by labor duration.

RESULTS

In this diverse sample (35.6% Caucasian, 16.11% African American, 40.2% Hispanic) of nulliparas with obesity (n = 87; BMI 35.54 ± 4.38 kg/m2), 31% ended labor with cesarean birth. Among those with vaginal birth, only 13% had MVU ≥200 prior to the final 2 hours of labor. MVUs were only minimally responsive to oxytocin dose and were not associated with labor progression nor birth route.

CONCLUSION

MVU measurements may not be useful to diagnose labor arrest in nulliparas with obesity. Optimizing care for birthing people with obesity is essential for improving perinatal outcomes and for reducing racial health disparities.

Innovations in Prospective Perinatal Research as a Result Of the COVID-19 Pandemic

In 2020, in‐person research activities were stopped because of the spread of the novel coronavirus, severe acute respiratory syndrome coronavirus 2, and the resulting disease, coronavirus disease 2019. Our collaborative team of nurse and midwife scientists at universities across the United States adapted research activities to continue prospective perinatal research during the pandemic. These adaptations included development of new research techniques and the implementation of previously developed, but underused, strategies to conduct research from a distance. These strategies included online recruitment, virtual enrollment and consent, qualitative data collection via video conferencing, new applications of smart phone technology, wearable biological measurement, and participant self‐collection of biological samples. In addition to allowing research to continue during the pandemic, these innovative strategies may increase access to research for low‐income, rural, and racially diverse pregnant and postpartum populations. Decreased travel requirements, flexible scheduling, wearable devices, and the capacity to self‐collect biologic samples may improve recruitment and the experience of research participation. The rapid implementation of these research strategies has advanced innovation toward wider, more inclusive and increasingly diverse perinatal research access, and many of these strategies will continue to be used and refined.

Racial Disparities in Stillbirth Risk Factors among non-Hispanic Black Women and non-Hispanic White Women in the United States

INTRODUCTION

Historically, stillbirth risk factors are more prevalent among non-Hispanic Black women than non-Hispanic White women, including age < 20, lower formal educational attainment, prepregnancy obesity, smoking, hypertension, diabetes, short interpregnancy interval, small for gestational age newborn, late prenatal care, and previous cesarean birth. We examined whether these disparities have changed since 2011 and identified a group of risk factors that differed between Black women and White women when accounting for correlations among variables.

METHODS

In a random sample of 315 stillbirths from the National Center for Health Statistics' 2016 fetal death data, Black women and White women were compared for each risk factor using t-tests or chi-square tests. Variables with p ≤ .20 were analyzed using multivariate analysis of variance.

RESULTS

In this sample, Black women experiencing stillbirth were less likely to have a Bachelor's degree (12.94% vs. 28.49%, p = .04), and more likely to be obese (44.5% vs. 29.1%, p = .01) than White women. Multivariate analysis accounting for correlations among variables showed a group of risk factors that differed between Black women and White women: age < 20, lower education, prepregnancy obesity, hypertension (chronic and pregnancy-associated), nulliparity before stillbirth, and earlier gestation.

CLINICAL IMPLICATIONS

Less formal education, obesity, age <20, hypertension, chronic and pregnancy-associated, nulliparity, and earlier gestation are important to consider in multilevel stillbirth prevention interventions to decrease racial disparity in stillbirth. Respectfully listening to women and taking their concerns seriously is one way nurses and other health care providers can promote equity in health outcomes for childbearing women.

Sex-differences in initiation of renin-angiotensin system inhibitors in patients with type 2 diabetes diagnosed with albuminuria

Background

Renin-angiotensin system inhibitors (RASi) are the preferred drug of choice in patients with type 2 diabetes (T2D) and albuminuria to prevent progression of chronic renal disease and cardiovascular complications. However, it is unknown whether sex-differences exist in the initiation of RASi in patients with T2D and albuminuria, and potential sex-differences in the effect of RASi on all-cause death in these patients remains untested.

Purpose

To examine potential sex-differences in the initiation of RASi in patients with T2D and albuminuria, and secondly whether these sex-differences are associated with mortality risk.

Methods

Using Danish nationwide registers, we included patients with their first albumin-creatinine ratio (ACR; index date) of ≥30 mg/g between 1 January 2014 and 20 March 2019 in patients with T2D with no prior end-stage renal disease, no acute renal failure within 90 days, and no claimed prescriptions of RASi within 15 years. We used multiple Cox regression to study the hazard ratio (HR; men vs women) of 30-day RASi initiation. In 30-day survivors, we used another multiple Cox regression to compare mortality between patients who initiated RASi and patients who did not yet initiate RASi. Reported were the sex-specific standardized 1-year risk differences for fixed comorbidity distribution according to RASi treatment.

Results

In 20,440 patients (44% women), 1,190 men and 682 women initiated RASi treatment within 30 days after index. The adjusted rate of RASi initiation was higher in men compared to women (HR 1.34 [1.22; 1.48]). This association was observed regardless of hypertension (no: HR 1.35 [1.20; 1.52]; yes: HR 1.34 [1.14; 1.57]) and ACR-group ((30–300] mg/g: HR 1.35 [1.22; 1.49]; ≥300 mg/g: HR 1.30 [0.98; 1.73]), although borderline significant for ACR ≥300 mg/g (p=0.071). The association declined with descending estimated glomerular filtration rate (eGFR) and was not significant for eGFR group (15–60] (eGFR (90–120]: HR 1.45 [1.28; 1.65]; (60–90]: HR 1.25 [1.06; 1.47]; (15–60]: HR 1.07 [0.77; 1.48]). 30 days after index, 49 patients (37% women) had died, and 9 patients (33% women) had emigrated. In 30-day survivors, the standardized 1-year mortality risk was 1.9% [1.4; 2.4] in men who readily initiated RASi, and 3.3% [3.0; 3.7] in men who did not (absolute reduction: 1.5% [0.9; 2.0]). In contrast, the absolute reduction was not significant in women (0.1% [−0.5; 0.8]). Standardizing according to sex, the associated 1-year mortality risk was 3.4% [3.1; 3.7] in men without RASi, and 2.8% [2.5; 3.0] in women (absolute risk difference 0.6% [0.3; 0.9]). In contrast, men with RASi were borderline significantly associated with a lower 1-year mortality risk compared to women with RASi (absolute risk difference 0.8% [0.0; 1.5], p=0.042).

Conclusions

In patients with T2D and albuminuria, men are more likely to initiate RASi within 30 days, and RASi appears to be associated with greater benefit on 1-year mortality risk in men.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Figure 1Figure 2

Review of Evidence-Based Methods for Successful Labor Induction

Induction of labor is increasingly a common component of the intrapartum care. Knowledge of the current evidence on methods of labor induction is an essential component of shared decision-making to determine which induction method meets an individual's health needs and personal preferences. This article provides a review of the current research evidence on labor induction methods, including cervical ripening techniques, and contraction stimulation techniques. Current evidence about expected duration of labor following induction, use of the Bishop score to guide induction, and guidance on the use of combination methods for labor induction are reviewed.

Increased vulnerability to COVID-19 in chronic kidney disease

BACKGROUND

The significance of chronic kidney disease on susceptibility to COVID-19 and subsequent outcomes remains unaddressed.

OBJECTIVE

To investigate the association of estimated glomerular filtration rate (eGFR) on risk of contracting COVID-19 and subsequent adverse outcomes.

METHODS

Rates of hospital-diagnosed COVID-19 were compared across strata of eGFR based on conditional logistic regression using a nested case-control framework with 1:4 matching of patients diagnosed with COVID-19 with controls from the Danish general population on age, gender, diabetes and hypertension. Risk of subsequent severe COVID-19 or death was assessed in a cohort study with comparisons across strata of eGFR based on adjusted Cox regression models with G-computation of results to determine 60-day risk standardized to the distribution of risk factors in the sample.

RESULTS

Estimated glomerular filtration rate was inversely associated with rate of hospital-diagnosed COVID-19: eGFR 61-90 mL/min/1.73m² HR 1.13 (95% CI 1.03-1.25), P = 0.011; eGFR 46-60 mL/min/1.73m²   HR 1.26 (95% CI 1.06-1.50), P = 0.008; eGFR 31-45 mL/min/1.73m² HR 1.68 (95% CI 1.34-2.11), P < 0.001; and eGFR ≤ 30 mL/min/1.73m² 3.33 (95% CI 2.50-4.42), P < 0.001 (eGFR > 90 mL/min/1.73m² as reference), and renal impairment was associated with progressive increase in standardized 60-day risk of death or severe COVID-19; eGFR > 90 mL/min/1.73m² 13.9% (95% CI 9.7-15.0); eGFR 90-61 mL/min/1.73m² 16.1% (95% CI 14.5-17.7); eGFR 46-60 mL/min/1.73m² 17.8% (95% CI 14.7-21.2); eGFR 31-45 mL/min/1.73m² 22.6% (95% CI 18.2-26.2); and eGFR ≤ 30 mL/min/1.73m² 23.6% (95% CI 18.1-29.1).

CONCLUSIONS

Renal insufficiency was associated with progressive increase in both rate of hospital-diagnosed COVID-19 and subsequent risk of adverse outcomes. Results underscore a possible vulnerability associated with impaired renal function in relation to COVID-19.

Challenges in the Triage Care of Low-Risk Laboring Patients: A Comparison of 2 Models of Practice

Triage and the timing of admission of low-risk pregnant women can affect the use of augmentation, epidural, and cesarean. The purpose of this analysis was to explore these outcomes in a community hospital by the type of provider staffing triage. This was a retrospective cohort study of low-risk nulliparous women with a term, vertex fetus laboring in a community hospital. Bivariate and multivariable statistics evaluated associations between triage provider type and labor and birth outcomes. Patients in this sample (N = 335) were predominantly White (89.5%), with private insurance (77.0%), and married (71.0%) with no significant differences in these characteristics by triage provider type. Patients admitted by midwives had lower odds of oxytocin augmentation (adjusted odds ratio [aOR] = 0.50, 95% confidence interval [CI] = 0.29-0.87), epidural (aOR = 0.29, 95% CI = 0.12-0.69), and cesarean birth (aOR = 0.308, 95% CI = 0.14-0.67), compared with those triaged by physicians after controlling for patient characteristics and triage timing. This study provides additional context to midwives as labor triage providers for healthy, low-risk pregnant individuals; however, challenges persisted with measurement. More research is needed on the specific components of care during labor that support low-risk patients to avoid medical interventions and poor outcomes.

The association between longer durations of the latent phase of labor and subsequent perinatal processes and outcomes among midwifery patients

BACKGROUND/OBJECTIVE

To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes.

METHODS

Secondary analysis of prospectively collected data among 1,189 women with low-risk pregnancies and spontaneous labor.

RESULTS

Longer latent phase duration was associated with labor dystocia (eg, nulliparous ≥ mean [compared with < mean] aOR 3.95 [2.70-5.79]; multiparous ≥ mean [compared with < mean] aOR 5.45 [3.43-8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous > 80th% [compared with < 80th%] aOR 6.39 [4.04-10.12]; multiparous ≥ 80th% [compared with < 80th%] aOR 6.35 [3.79-10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with < 80th%] aOR 2.7 [1.22-5.84]); however, two-thirds of these NICU admissions were likely for observation only.

CONCLUSIONS

Longer duration of the spontaneous latent phase of labor among women with low-risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor.

Multifactorial intervention and effect on morbidity, preventive medication and mortality in patients with type 2 diabetes within cardiac rehabilitation

Background

Although studies have reported beneficial impact of cardiac rehabili-ta-tion in the overall population, knowledge from clinical randomized trials of the effect of cardiac rehabilitation in patients with type 2 diabetes is still sparse.

Purpose

In the randomized DANSUK trial, we aimed to evaluate the short- and long-term effect on cardiovascular disease, hospital readmissions, mortality and use of preventive medication in patients with type 2 diabetes referred to comprehensive cardiac rehabilitation by comparing an intensified, targeted, multifactorial intervention with standard of care.

Methods

From 2000 to 2004 a total of 151 patients with type 2 diabetes and with ischemic heart disease (53%), heart failure (18%), or high-risk patients with at least three risk factors for ischemic heart disease (29%) were included in the DANSUK trial. The patients were allocated to standard of care (N=76) following current guidelines or comprehensive cardiac rehabilitation during a twelve weeks program with a stepwise implementation of behaviour modification and preventive medication to reach treatment goals (N=75). Clinical outcomes were compared after three and fourteen years of follow-up using national registries. Primary composite outcome measure included overall mortality, myocardial infarction or acute first-time readmission.

Results

Mean age was 66 years and more than one third of the population were women. After three years of follow-up, no difference in primary outcome was obtained (HR: 0,87; 95% CI: 0,58–1,32), but when hospitalized within the first three years, mean length of stay was significantly reduced by 25% in patients who had attended comprehensive cardiac rehabilitation compared to standard of care (5,8 vs. 7,7 days; p&lt;0.04). After fourteen years of follow-up there was still no difference in the combined endpoint between the two treatment groups.

Conclusions

Although the DANSUK trial earlier has demonstrated reductions in several risk factors and in the use of preventive medication in patients with abnormal glucose metabolism attending comprehensive cardiac rehabilitation compared to standard of care, these effects did not translate into the primary composite endpoint after three and fourteen years of follow-up in patients with known type 2 diabetes at enrolment. Nevertheless, there was a significant reduction in length of stay when admitted to hospital in the cardiac rehabilitation group compared to standard of care within the first three years of follow-up.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Danish Heart Foundation

Metabolomics Research Conducted by Nurse Scientists: A Systematic Scoping Review

Metabolomics, one of the newest omics, allows for investigation of holistic responses of living systems to myriad biological, behavioral, and environmental factors. Researcher use metabolomics to examine the underlying mechanisms of clinically observed phenotypes. However, these methods are complex, potentially impeding their uptake by scientists. In this scoping review, we summarize literature illustrating nurse scientists' use of metabolomics. Using electronic search methods, we identified metabolomics investigations conducted by nurse scientists and published in English-language journals between 1990 and November 2019. Of the studies included in the review (N = 30), 9 (30%) listed first and/or senior authors that were nurses. Studies were conducted predominantly in the United States and focused on a wide array of clinical conditions across the life span. The upward trend we note in the use of these methods by nurse scientists over the past 2 decades mirrors a similar trend across scientists of all backgrounds. A broad range of study designs were represented in the literature we reviewed, with the majority involving untargeted metabolomics (n = 16, 53.3%) used to generate hypotheses (n = 13, 76.7%) of potential metabolites and/or metabolic pathways as mechanisms of clinical conditions. Metabolomics methods match well with the unique perspective of nurse researchers, who seek to integrate the experiences of individuals to develop a scientific basis for clinical practice that emphasizes personalized approaches. Although small in number, metabolomics investigations by nurse scientists can serve as the foundation for robust programs of research to answer essential questions for nursing.

5878Renal insufficiency is associated with progressive increase in risk of cardiovascular death in patients without preexisting cardiovascular disease

Introduction and aims

Chronic kidney disease has previously been observed to be associated with increased cardiovascular risk. Observations are however predominantly limited to patients with either severe or end-stage renal disease. We investigate the associated risk of diminishing renal function with cardiovascular death across all levels of non-dialysis dependent renal insufficiency.

Methods

Based on cross-referencing of data from numerous nationwide health care registers, patients with a recorded plasma creatinine measurement were identified in Denmark between 1997 and 2017. Patients with preceding cardiovascular disease, end-stage renal disease, age <18 years, and patients with events within a 30 days quarantine period after their first-time plasma creatinine measurement were excluded. Estimated glomerular filtration rates (eGFRs) were calculated from the first recorded plasma creatinine. Hazard ratios for two-year risk of cardiovascular death were computed for strata of renal function in a multiple Cox regression model with adjustment for age and gender, and cumulative incidences were estimated using the Aalen-Johansen estimator.

Results

In total 2,000,626 patients were identified. Median follow-up was 3.6 years (IQR 1.7–9.0 years). A total of 22,657 (0.01%) cardiovascular deaths were recorded. Patients were predominantly female (54%), median age was 40 years (IQR 29–63 years), and median eGFR was 98 ml/min/1.73m2 (IQR 83–117 ml/min/1.73m2). Hazard ratios with confidence intervals of cardiovascular death were 0.85 [0.82–0.89], 1.24 [1.18–1.31], 2.02 [1.89–2.15], and 3.19 [2.91–3.49] for the eGFR strata 90–60 ml/min/1.73m2, 59–45 ml/min/1.73m2, 44–30 ml/min/1.73m2, <30 ml/min/1.73m2, respectively (eGFR >90 ml/min/1.73m2 as reference).

Cumulative incidence

Conclusion

In a nationwide cohort of non-dialysis treated patients without pre-existing cardiovascular disease, renal dysfunction was associated with progressive increase in risk of cardiovascular death in patients with eGFR <60 ml/min/1.73m2.

P1953Risk of upper gastrointestinal bleeding following myocardial infarction: a novel prediction model for assessing appropriateness of proton pump inhibition therapy

Background

Upper gastrointestinal bleeding following myocardial infarction continues to be a severe complication associated with increased mortality; however, bleeding events might be avoided by appropriate therapy with proton pump inhibitors.

Purpose

To develop and validate a prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding following myocardial infarction.

Methods

Based on multiple nationwide Danish registers, all patients initiating dual antiplatelet or anticoagulant therapy in combination with antiplatelet following myocardial infarction between 2003 and 2016 were identified. Primary outcome of interest was one-year risk of upper gastrointestinal bleeding. A derivation cohort including all patients between 2003 and 2013 was selected, whereas patients identified between 2014 and 2016 was employed for internal validation. Multiple logistic regression was used to predict person specific risks based on age, history of gastrointestinal bleeding or peptic ulcer, anaemia or gastrointestinal cancer, use of nonsteroidal anti-inflammatory drugs, oral anticoagulants, selective serotonin reuptake inhibitors or loop diuretics. We compared our model with the European Society of Cardiology (ESC) guideline recommendation on gastrointestinal bleeding risk assessment.

Results

A total of 61 543 patients with myocardial infarction were identified for the study. In the total cohort, the median age was 68 years (IQR: 58–77), 85.0% (52 334) underwent coronary angiography, 2.6% (1 608) had a history of gastrointestinal bleeding and 7.1% (4 354) used oral anticoagulants. The average one-year risk of upper gastrointestinal bleeding was 1.04% (95% CI: 0.95–1.14%), and mean predicted risk of the model was 1.04% (IQR: 0.64–1.26%). The discriminative ability of the model evaluated by area under the curve was 74.2% (95% CI: 66.9–78.6%) in the validation cohort. The proposed risk model demonstrated improved sensitivity and specificity at the specific threshold of the ESC risk schemes (Figure 1). Results remain principally unchanged regardless of inclusion or exclusion of patients initiating proton pump inhibitors at baseline. Furthermore, using cross-validation for the model evaluation produced similar discrimination results.

Figure 1

Conclusion

Based on nationwide registers a novel prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding was developed and validated; the model observed moderate discrimination in the validation cohort providing possible benefit for clinicians in terms of communicating absolute risk to the patients and determining the appropriateness of initiating preventive therapy.

Acknowledgement/Funding

The Danish Heart Foundation

Long-term use of proton pump inhibitors, dose-response relationship and associated risk of ischemic stroke and myocardial infarction

BACKGROUND

Use of proton pump inhibitors (PPIs) has been associated with cardiovascular disease amongst patients not on antiplatelet therapy. The associations of PPI use, duration and dose, with risk of first-time ischemic stroke and myocardial infarction (MI) are poorly understood.

METHODS

All Danish individuals with no prior history of MI or stroke, who had an elective upper gastrointestinal endoscopy performed between 1997 and 2012, were identified from nationwide registries. We used multiple Poisson regression to test associations with current PPI use and its dose and used multiple cause-specific Cox regression and g-formula methods to analyze long-term use.

RESULTS

Amongst 214 998 individuals, during a median follow-up of 5.8 years, there were 7916 ischemic strokes and 5608 MIs. Current PPI exposure was associated with significantly higher rates of both ischemic stroke (Hazard ratio (HR) 1.13; 95% confidence interval (CI) 1.08-1.19) and MI (HR 1.31, CI 1.23-1.39) after adjusting for age, sex, comorbidities and concomitant medication. High-dose PPI was associated with increased rates of ischemic stroke (HR 1.31, CI 1.21-1.42) and MI (HR 1.43, CI 1.30-1.57). Histamine H2 receptor antagonists (H2RAs) use was not significantly associated with ischemic stroke (HR 1.02, CI 0.84-1.24) or MI (HR 1.15, CI 0.92-1.43). Long-term users of PPIs, compared with nonusers, had a 29% (CI 5%-59%) greater absolute risk of ischemic stroke and a 36% (CI 7%-73%) greater risk of MI within a 6-month period.

CONCLUSION

Use of PPIs was associated with increased risks of first-time ischemic stroke and MI, particularly amongst long-term users and at high doses.

The presence of Waddell signs depends on age and gender, not diagnosis

Aims

The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life.

Patients and Methods

This prospective cross-sectional study included 479 adult patients with back pain from a university spine centre. Each completed SF-12 and Oswestry Disability Index (ODI) questionnaires and underwent standard spinal examinations to elicit Waddell signs. The relationship between Waddell signs and age, gender, ODI, Mental Component Score (MCS), and Physical Component Score (PCS) scores was determined.

Results

Of the 479 patients, 128 (27%) had at least one positive Waddell sign. There were significantly more women with two or more Waddell signs than men. The proportion of patients with at least one positive Waddell sign increased with age until 55 years, and then declined rapidly; none had a positive sign over the age of 75 years. Functional outcome scores were significantly worse in those with a single Waddell sign (p < 0.01). With one or more Waddell signs, patients’ PCS and ODI scores indicated a perception of severe disability; with three or more Waddell signs, patients’ MCS scores indicated severe disability. With five Waddell signs, ODI scores indicated that patients perceived themselves as crippled.

Conclusion

Positive Waddell signs, a potential indicator of central sensitization, indicated a likelihood of having functional limitations and an impaired quality of life, particularly in young women. Cite this article: Bone Joint J 2018;100-B:219–25.

Regulation of dendrite growth and maintenance by exocytosis

Dendrites lengthen by several orders of magnitude during neuronal development, but how membrane is allocated in dendrites to facilitate this growth remains unclear. Here, we report that Ras opposite (Rop), the Drosophila ortholog of the key exocytosis regulator Munc18-1 (also known as STXBP1), is an essential factor mediating dendrite growth. Neurons with depleted Rop function exhibit reduced terminal dendrite outgrowth followed by primary dendrite degeneration, suggestive of differential requirements for exocytosis in the growth and maintenance of different dendritic compartments. Rop promotes dendrite growth together with the exocyst, an octameric protein complex involved in tethering vesicles to the plasma membrane, with Rop-exocyst complexes and exocytosis predominating in primary dendrites over terminal dendrites. By contrast, membrane-associated proteins readily diffuse from primary dendrites into terminals, but not in the reverse direction, suggesting that diffusion, rather than targeted exocytosis, supplies membranous material for terminal dendritic growth, revealing key differences in the distribution of materials to these expanding dendritic compartments.

Abstract 2466: Characterization and development of on-target Mcl-1 inhibitors; BH3 profiling provides a valuable drug discovery tool

Anti-apoptotic Bcl-2 family proteins are central to the regulation of the intrinsic apoptotic pathway, and as such constitute an important group of targets with great potential as oncology therapeutics. The Bcl-2 family protein Mcl-1 has been demonstrated to facilitate survival and chemoresistance in multiple myeloma, AML, and other cancers, and agents which affect this pathway have become highly sought after. Currently, however, no therapies exist which directly target Mcl-1. We have identified compounds that target Mcl-1 which may be characterized as both Mcl-1-selective and pan-Mcl-1/Bcl-2 inhibitors. This effort has been facilitated by utilization of the BH3 profiling technology to guide SAR. This assay allows for determination of the mitochondrial priming state of both cell culture samples and primary patient samples. We have demonstrated a correlation between myeloma and leukemia cell line response to treatment with our inhibitors and the mitochondrial priming state of such cell lines. Such correlations have also been shown with respect to the extent of cytochrome C release. In the case of the selective Mcl-1 inhibitor, we have shown that cytochrome C release occurs preferentially in leukemia cell lines which are highly primed for Mcl-1 rather than Bcl-2. In addition, our Mcl-1 selective inhibitor demonstrates enhanced cell killing ability in leukemia cells which have been engineered to selectively express Mcl-1, Bcl-2, and Bcl-xL. Our current lead candidate possesses excellent drug-like properties and displays impressive efficacy in a multiple myeloma disseminated xenograft model. This work demonstrates the utility of the BH3 profiling assay as providing a functional biomarker for drug discovery tool and its ability to validate the on-target activity of Mcl-1 and Bcl-2 inhibitors.

Citation Format: David J. Richard, Nicole Carlson, William Pierceall, Ryan Lena, Thomas Bannister, Peter Hodder, Timothy Spicer, Michael Andreeff, Joseph Opferman, Brian Koss, Andrew Kung, Michael Cardone. Characterization and development of on-target Mcl-1 inhibitors; BH3 profiling provides a valuable drug discovery tool. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2466. doi:10.1158/1538-7445.AM2013-2466

Overview of breast cancer treatment and reconstruction for primary care providers

More women are diagnosed and treated for breast cancer today than at any time in the past. New technologies in the treatment of breast cancer and breast reconstruction are changing morbidity and mortality realities for women diagnosed with breast cancer. Primary care providers in women's health care can provide valuable support, education, and advocacy for their clients who are dealing with breast cancer. This article reviews current breast cancer treatment guidelines, information on breast reconstruction after cancer, and primary care recommendations for post-breast cancer care.

Sample-to-sample fluctuations in real-network ensembles

Network modeling based on ensemble averages tacitly assumes that the networks meant to be modeled are typical in the ensemble. Previous research on network eigenvalues, which govern a range of dynamical phenomena, has shown that this is indeed the case for uncorrelated networks with minimum degree ≥ 3. Here, we focus on real networks, which generally have both structural correlations and low-degree nodes. We show that: (i) the ensemble distribution of the dynamically most important eigenvalues can be not only broad and far apart from the real eigenvalue but also highly structured, often with a multimodal rather than a bell-shaped form; (ii) these interesting properties are found to be due to low-degree nodes, mainly those with degree ≤ 3, and network communities, which is a common form of structural correlation found in real networks. In addition to having implications for ensemble-based approaches, this shows that low-degree nodes may have a stronger influence on collective dynamics than previously anticipated from the study of computer-generated networks.

Mutation screening of mitofusin 2 in Charcot-Marie-Tooth disease type 2

Charcot-Marie-Tooth (CMT) disease is among the most common inherited neurological disorders. Mutations in the gene mitofusin 2 (MFN2) cause the axonal subtype CMT2A, which has also been shown to be associated with optic atrophy, clinical signs of first motor neuron involvement, and early onset stroke. Mutations in MFN2 account for up to 20-30% of all axonal CMT type 2 cases. To further investigate the prevalence of MFN2 mutations and to add to the genotypic spectrum, we sequenced all exons of MFN2 in a cohort of 39 CMT2 patients. We identified seven variants, four of which are novel. One previously described change was co-inherited with a PMP22 duplication, which itself causes the demyelinating form CMT1A. Another mutation was a novel in frame deletion, which is a rare occurrence in the genotypic spectrum of MFN2 characterized mainly by missense mutations. Our results confirm a MFN2 mutation rate of ~15-20% in CMT2.

BH3 profiling identifies three distinct classes of apoptotic blocks to predict response to ABT-737 and conventional chemotherapeutic agents

Cancer cells exhibit many abnormal phenotypes that induce apoptotic signaling via the intrinsic, or mitochondrial, pathway. That cancer cells nonetheless survive implies that they select for blocks in apoptosis. Identifying cancer-specific apoptotic blocks is necessary to rationally target them. Using a panel of 18 lymphoma cell lines, we show that a strategy we have developed, BH3 profiling, can identify apoptotic defects in cancer cells and separate them into three main classes based on position in the apoptotic pathway. BH3 profiling identifies cells that require BCL-2 for survival and predicts sensitivity to the BCL-2 antagonist ABT-737. BCL-2 dependence correlates with high levels of proapoptotic BIM sequestered by BCL-2. Strikingly, BH3 profiling can also predict sensitivity to conventional chemotherapeutic agents like etoposide, vincristine, and adriamycin.

Perineal body length and lacerations at delivery

OBJECTIVE

To define normal perineal body length during labor and determine if a shortened perineal body is associated with perineal lacerations or operative vaginal delivery.

STUDY DESIGN

We reviewed charts of patients admitted for labor over a 4-month period. The perineal body was measured by the admitting physician and delivery outcomes obtained from inpatient records. Patients were excluded for malpresentation, multiple gestation, gestational age < 36 weeks, incomplete records and scheduled cesarean delivery. To determine if differences existed between patients with perineal body measurements available and those without, chi2 analysis was used, with P<.05 considered significant. Multiple logistic regression was used to control for confounding variables and determine if a shortened perineal body affected the incidence of operative vaginal delivery and significant lacerations at vaginal delivery.

RESULTS

A total of 234 patients met our inclusion criteria; perineal body measurements were available for 133 (57%). The average perineal body length was 3.90 cm (+/-0.70). Patients with a perineal body of < or = 2.5 cm had a significantly higher chance of sustaining a third- or fourth-degree laceration (40% vs. 5.6%, P=.004). This risk remained after controlling for both operative vaginal delivery and episiotomy. The incidence of operative vaginal delivery was greater (28.5% vs. 9.2%, P =.006) for patients with a perineal body < or = 3.5 cm.

CONCLUSION

There is an increased risk of significant lacerations and operative vaginal delivery in patients with a shortened perineal body.

Successful management of metastatic placental site trophoblastic tumor with multiple pulmonary resections

INTRODUCTION

Placental site trophoblastic tumor (PSTT) is an uncommon variant of gestational trophoblastic disease. Most of these tumors are confined to the uterus and treated with a simple hysterectomy. However, 30% of these patients will present with metastatic disease. These patients are typically treated with a hysterectomy followed by adjuvant multiagent chemotherapy. Unfortunately, PSTT is relatively resistant to chemotherapy when compared to other forms of gestational trophoblastic disease. Consequently, these patients have a poor prognosis.

CASE

We present a case report of a 26-year-old female with multiple metastatic lesions to the lungs unresponsive to chemotherapy who was managed with multiple pulmonary resections. She has remained clinically free of disease at 28 months of follow up.

CONCLUSION

A patient with metastatic PSTT was successfully managed with radical surgical resection of chemotherapy-resistant sites.

Overexpression of the neutral amino acid transporter ASCT2 in human colorectal adenocarcinoma

Cancer cells have increased amino acid transport and retention. Our aim was to determine whether the neutral amino acid transporter ASCT2 is expressed in colorectal adenocarcinomas (CRC), and whether its expression is of biological significance. Western blot analysis was performed on 4 cases of CRC. Immunohistochemical staining was performed on sections of 63 CRC, and the percent of positive cells was determined. Survival analysis was performed using the Kaplan-Meier method. Western blot analysis showed a 50 kDa protein, corresponding to ASCT2, in 3 of the 4 CRC samples. Immunohistostaining showed lack of ASCT2 immunoreactivity in 41% of the cases. ASCT2 immunoreactivity was present in 1-25% of the cancer cells in 24% of the cases, 26-50% of the cells in 13%, and in > 50% of the cells in 22% of the cases. Patient survival decreased with increased percentage of ASCT2-positive cancer cells (p = 0.0002). These results indicate that ASCT2 is expressed in a significant number of CRC, and that ASCT2 expression is associated with aggressive biological behavior. Larger studies with multivariate analysis are needed to determine whether ASCT2 expression is an independent prognostic marker in CRC.

Acid suppression therapy may not alter malignant progression in Barrett's metaplasia showing p53 protein accumulation

OBJECTIVES

Several previous studies have shown that malignant progression in Barrett's metaplasia (BM) occurs even in patients treated with fundoplication or acid suppression therapy (AST). The aim of this study was to test the hypothesis that AST may not alter malignant progression in BM if key genes involved in DNA repair and cell cycle control, particularly p53, are defective.

METHODS

Initial and follow-up biopsies from 21 patients with BM treated with AST and observed for 1-13 yr were entered in the study. All biopsies were graded for dysplasia and evaluated for p53 protein accumulation and oxidative DNA damage by immunohiostochemistry, using antibodies to p53 and to 8-hydroxydeoxyguanosine, respectively. DNA ploidy was determined using image analysis. Statistical analysis was performed using Kaplan-Meier curves, log rank test, and multivariate regression.

RESULTS

Patients with p53 positive initial biopsies were more likely to have progression in dysplasia grade (p = 0.022) and DNA ploidy status (p = 0.023) than those with p53 negative biopsies. In eight patients AST resulted in significant reduction in oxidative DNA damage in the five patients with p53-negative initial biopsies, but not the three with p53 positive ones (p = 0.0007).

CONCLUSIONS

We conclude that failure of AST to alter malignant progression in BM may be due, at least in part, to defects in DNA repair and cell cycle control resulting from p53 gene mutation, present before AST treatment. Although AST may be effective in preventing further DNA damage, it is unlikely to alter progression in genetically unstable cells.

Acid suppression therapy may not alter malignant progression in Barrett's metaplasia showing p53 protein accumulation

OBJECTIVES

Several previous studies have shown that malignant progression in Barrett's metaplasia (BM) occurs even in patients treated with fundoplication or acid suppression therapy (AST). The aim of this study was to test the hypothesis that AST may not alter malignant progression in BM if key genes involved in DNA repair and cell cycle control, particularly p53, are defective.

METHODS

Initial and follow-up biopsies from 21 patients with BM treated with AST and observed for 1-13 yr were entered in the study. All biopsies were graded for dysplasia and evaluated for p53 protein accumulation and oxidative DNA damage by immunohiostochemistry, using antibodies to p53 and to 8-hydroxydeoxyguanosine, respectively. DNA ploidy was determined using image analysis. Statistical analysis was performed using Kaplan-Meier curves, log rank test, and multivariate regression.

RESULTS

Patients with p53 positive initial biopsies were more likely to have progression in dysplasia grade (p = 0.022) and DNA ploidy status (p = 0.023) than those with p53 negative biopsies. In eight patients AST resulted in significant reduction in oxidative DNA damage in the five patients with p53-negative initial biopsies, but not the three with p53 positive ones (p = 0.0007).

CONCLUSIONS

We conclude that failure of AST to alter malignant progression in BM may be due, at least in part, to defects in DNA repair and cell cycle control resulting from p53 gene mutation, present before AST treatment. Although AST may be effective in preventing further DNA damage, it is unlikely to alter progression in genetically unstable cells.

Expression of the vascular endothelial growth factor receptor-3 (VEGFR-3) and its ligand VEGF-C in human colorectal adenocarcinoma

Vascular endothelial growth factors (VEGF) are secreted by many tumor types, and are believed to affect tumor growth by promoting angiogenesis through binding to their receptors present on vascular endothelium. Recently, mRNA for VEGF-C the ligand for VEGFR-3, was found to be up-regulated in colorectal adenocarcinoma (CRC). The aim of this work was to determine: 1) the distribution of VEGF-C and VEGFR-3 in CRC, and 2) the biological significance of such expression. Sections of formalin-fixed and paraffin-embedded tissues from 56 CRC were immunohistochemically stained for VEGF-C and VEGFR-3. The type and percent of positive cells was recorded. Survival analysis was performed using the Kaplan-Meier method. All CRC were positive for VEGF-C which was present in the cancer cells themselves, as well as in stromal cells. Normal colon epithelium was usually negative. Only ten (17%) of the 56 CRC completely lacked VEGFR-3 expression. VEGFR-3 immunoreactivity was detected in <25% of the cancer cells in 22 cases and in >25% of the cells in 34 cases. Expression of VEGFR-3 in >25% of the cancer cells was associated with significantly poorer overall survival (p<0.05), but not with lymph node metastasis or depth of tumor invasion. Our results suggest that VEGFs promote cancer growth not only by stimulating angiogenesis, but also by acting on receptors present on the cancer cells themselves.

Opening farm gates: community as educator

This paper presents the experience of five undergraduate Bachelor of Nursing students who undertook a clinical practice placement in a rural community. This, our first engagement with nursing, was a profound learning experience. We did not expect the intense contributions the rural community as a whole would make to our understandings of rural health care in general, and rural nursing in particular. Initially, we felt like outsiders to the rural community as well as the profession of nursing. The interwoven nature of community relationships combined with our acute sense of being highly visible in the township led to us developing a sense of vulnerability. We believed we needed to portray a professional image during all social interactions with the community and this compounded our insecurities during the clinical placement. Before long, we found the rural population embracing and very supportive of our placement. However, we found ourselves questioning whether we would return to a rural community to work as nurses on the basis of our lack of privacy during this time.

Hospital nursing benchmarks: the California Nursing Outcomes Coalition project

The California Nursing Outcomes Coalition (CalNOC) project is an initiative that has become the largest ongoing nursing quality measurement repository in the nation. Launched in 1996 by California nursing leaders concerned with trends in hospital care, CalNOC has created reliable quality benchmark data to define patient safety thresholds in California. This article describes CalNOC's effort, which aligns with the strategy of the National Quality Forum for measuring and reporting healthcare quality. By tracing the evolution of the CalNOC project and its future potential, we hope to encourage other grassroots efforts to build the database repositories needed for healthcare quality measurement in the 21st century.

Neuronal nicotinic acetylcholine receptor expression by O2A/oligodendrocyte progenitor cells

Oligodendrocyte precursor cells (O2A/OPC, A2B5(+)) were examined for expression of neuronal nicotinic acetylcholine receptors (nAChR). RT-PCR analysis and immunocytochemistry of O2A/OPCs purified from the rat corpus collusum revealed the expression of nAChR subunits alpha3, alpha4, alpha5, alpha7, beta2, and beta4. Immunoreactivity toward nAChR subunits was not detected in cells induced to differentiate into either oligodendrocytes or astrocytes. Approximately 65% of O2A/OPCs loaded with the calcium-responsive dye FURA-2 increased their intracellular free calcium in response to nicotine application. This response was sensitive to the nAChRalpha4/beta2 antagonist, dihydro-beta-erythroidine (DHbetaE), and the voltage-gated calcium channel antagonist, nifedipine. A subset of nicotine-responsive cells (37%) established DHbetaE or nifedipine-sensitive intracellular free calcium oscillations that continued in the presence of nicotine. Typical oscillations occurred at intervals of 20 to 30 s with progressively diminished amplitudes over a period of 2 to 3 min. In rare cases, oscillations persisted for as long as 10 min. O2A/OPCs exposed to carbachol or AMPA produced no oscillations despite robust increases in intracellular free calcium. The expression of nAChRs in non-neuronal glial precursor cells suggests an expanded role for this receptor system in the development of the mammalian brain. GLIA 33:306-313, 2001. Published 2001 Wiley-Liss, Inc.

Estrogen receptor beta expression in invasive breast cancer

The aim of this work was to determine the extent of estrogen receptor beta (ER-beta) expression in invasive breast cancer (BrCA) and whether ER-beta expression is correlated with response to adjuvant hormonal therapy with tamoxifen (AHTT). Immunohistochemical staining (IHC) for estrogen receptor alpha (ER-alpha) and ER-beta was performed on sections of formalin-fixed and paraffin-embedded tissue from 47 unselected invasive breast carcinomas (BrCA). IHC for ER-beta was also performed on sections of BrCA from 118 women who were treated with mastectomy and AHTT. Survival analysis was performed using the Kaplan-Meier method and the log-rank test. Of the 47 unselected BrCA, 17 (36%) were negative for ER-alpha and of these, 8 (47% of ER-alpha negative cases and 17% of all 47 patients) were ER-beta positive. Five of the 8 ER-alpha negative and ER-beta positive cases were positive for ER biochemically. There was no correlation between ER-beta positivity and overall survival in the unselected group. By contrast, in the group of women treated with AHTT, expression of ER-beta in more than 10% of cancer cells was associated with better survival (P = .0077), even in women with node-negative BrCA (P = .0069). In conclusion, our results show that a significant number of women with BrCA are positive for ER-beta only, and may be determined to be ER-negative when currently available IHC is used. ER-beta status is a significant predictor of response to AHTT in women with BrCA. Larger studies with multivariate analysis are needed to confirm these findings.

Exploration of physicians' recommendations for activities in chronic low back pain

STUDY DESIGN

A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients.

OBJECTIVES

To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations.

SUMMARY OF BACKGROUND DATA

Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations.

METHODS

Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders.

RESULTS

Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms.

CONCLUSIONS

Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.

Relationship between dysplasia, p53 protein accumulation, DNA ploidy, and Glut1 overexpression in Barrett metaplasia

BACKGROUND

There is a need for molecular markers of malignant progression in Barrett metaplasia (BM). The aim of this study is to determine the relationship between dysplasia, p53 protein accumulation, DNA ploidy, and Glut1 in BM.

METHODS

Sections of esophageal biopsy specimens from 120 patients with BM were evaluated for dysplasia, p53 protein, and Glut1 expression by immunohistochemistry, and DNA ploidy by Feulgen stain and image analysis. In cases with diploid DNA histograms, the percentage cells in the G0G1 and G2M phases of the cell cycle were determined.

RESULTS

Of 108 diploid cases 19 (28%) of 69 cases with G0G1 > or = 90% or G2M > or = 8.33% were p53-positive, in contrast to only 1 (3%) of 39 cases with lower G0G1 or G2M (P = 0.0008). Of 32 p53-positive cases 11 (32%) were aneuploid, in contrast to none (0%) of 88 p53-negative cases (P < 0.0001). Ten (91%) of 11 aneuploid cases were high-grade dysplasial adenocarcinoma (HGD/CA), compared with only 1 (1%) of 109 diploid cases (P < 0.0001). Five (45%) of 11 cases with HGD/CA were Glut1-positive, in contrast to none (0%) of 109 cases without HGD/CA (P < 0.0001).

CONCLUSIONS

Our data strongly suggest that in BM, after oxidative DNA damage, as a result of gastroesophageal reflux, there is an increase in the percentage of cells in the G0G1 or G2M phases of the cell cycle to enable repair of damaged DNA; in some of these cases this is followed sequentially by p53 gene mutation and protein accumulation, DNA aneuploidy, HGD, and CA with or without Glut1 overexpression. These events can be detected in routinely processed biopsy samples.