A descriptive analysis of first trimester urinary concentrations of 14 bisphenol analogues in the MIREC Canadian pregnancy cohort

BACKGROUND

Concern over the health effects of BPA, particularly for the developing fetus, has led to an increasing use of bisphenol analogues in industrial and consumer products, which may be as hormonally active as BPA. Biomonitoring data for many bisphenol analogues, especially in pregnant populations, are limited.

METHODS

We measured concentrations of 14 bisphenol analogues in 1st trimester urine samples (n = 1851) from the Maternal-Infant Research on Environmental Chemicals (MIREC) Canadian pregnancy cohort (2008-2011). We examined patterns of exposure according to sociodemographic and sampling characteristics as well as occupation and frequency of consumption of canned fish within the previous 3 months.

RESULTS

BPA was detected in 89% of participants with a specific gravity standardized geometric mean concentration of 0.990 μg/L. Biphenol 4,4' (BP 4,4'), 4,4'-dihydroxydiphenyl ether (DHDPE), and bisphenol E (BPE) were detected in >97% of participants. Bisphenol F (BPF) and bisphenol S (BPS) were detected in >60% of participants. Specific gravity standardized geometric mean concentrations of these 5 compounds ranged from 0.024 to 0.564 μg/L. Nine bisphenol analogues were detected in <9% of participants. Concentrations of BP 4,4', DHDPE, and BPE were higher in younger women and those with higher pre-pregnancy BMI, lower household income, lower education, and among smokers. We found a similar pattern of differences in BPF for age, education, and smoking status while BPS similarly differed across categories of pre-pregnancy BMI. Participants who were unemployed or working in the service industry had higher molar sum of 7 bisphenol analogues than those working in healthcare, education, or an office setting. Canned fish consumption was not related to bisphenol analogue concentrations.

CONCLUSION

BP 4,4', DHDPE, BPE, BPF, and BPS were highly detected in 1st trimester urine samples in this large pan-Canadian pregnancy cohort. This suggests widespread exposure to these analogues around 2008-2011 and warrants further investigation into associations with health outcomes.

Metastases from gastric cancer presenting as colorectal lesions: a report of two cases and systematic review

Gastric cancer is common with well-established routes of spread. Metastasis to the colon or rectum is rare; however, we have recently managed two patients with this clinical picture. We present these cases together with a literature review of current practice. A systematic review in PubMed using the terms 'gastric cancer' and 'colorectal metastasis' was performed. The identified papers were screened for relevance and the reference lists of relevant papers were also reviewed to ensure capture of all relevant reports. Twenty-four papers containing 26 cases of gastric cancer with metastasis to the colon or rectum were found. There was wide variation in presentation and practice in these cases, which tended to be in patients with poor histopathological features. Diagnosis is often challenging owing to the unusual radiological appearance and submucosal nature of the metastatic lesions. Treatment ranges from palliative care to radical resection. Colorectal metastases from gastric primary cancer are rare, but cases are reported and should be part of the index of suspicion during the work-up of patients with lower gastrointestinal symptoms and a history of gastric cancer. Treatment options range from aggressive surgical resection to palliative care and should be centred on the patient's fitness and wishes.

Extranodal follicular lymphoma: a clinicopathological and genetic analysis of 15 cases arising at non-cutaneous extranodal sites

AIMS

Recent studies of primary cutaneous follicular lymphoma suggest that it represents a clinicopathological entity distinct from nodal follicular lymphoma (FL). The purpose of this study was to determine if FL arising at other extranodal sites is more closely related to FL occurring in the skin or in lymph nodes.

METHODS AND RESULTS

Fifteen cases of non-cutaneous extranodal follicular lymphoma (ENFL) were identified from the Scotland and Newcastle Lymphoma Group (SNLG) database. All were stage 1E at presentation and involved the tonsil (n = 3), palate (n = 3), skeletal muscle (n = 2), ileum (n = 2), duodenum (n = 1), stomach (n = 1), thyroid gland (n = 1), submandibular gland (n = 1) and fallopian tube (n = 1). Polymerase chain reaction for t(14;18) using primers to the major breakpoint cluster region was performed on 14 cases of ENFL and the incidence of the translocation compared with that found in 16 cases of stage 1 nodal FL. Clinical and follow-up data were obtained from the SNLG database for the 15 cases of ENFL and 87 cases of stage 1 nodal FL, and a comparison of outcomes made. Only 2/14 cases of ENFL had detectable t(14;18) compared with 9/16 stage 1 nodal FL (P < 0.01). Freedom from progression and disease-specific survival was similar for the 15 cases of ENFL and 87 cases of stage 1 nodal FL. However, 13/15 patients with ENFL were disease free at the end of follow-up compared with 49/87 stage 1 nodal FL (P < 0.02).

CONCLUSIONS

The low incidence of t(14;18) and favourable outcome encountered in ENFL in this study is similar to that previously found for primary cutaneous FL. These results support the concept of a subtype of FL lacking t(14;18) involving the major breakpoint cluster region, and with a propensity to arise at extranodal sites. Despite a high relapse rate, patients with ENFL are more likely to achieve complete remission and may ultimately have a more favourable long-term prognosis than those with equivalent nodal disease.

Modulation of gene expression by androgen and oestrogens in the testis and prostate of the adult rat following androgen withdrawal

Androgens are important for the structural and functional integrity of the testis and the prostate and this may in part be mediated by the aromatisation of testosterone to oestradiol. The aim of the present study was to establish an in vivo model that would allow the identification of genes, the expression of which was regulated acutely by androgen and/or oestrogen in the male reproductive system. In rats in which the Leydig cells were ablated by administration of ethane dimethane sulfonate (EDS) 6 days earlier, testosterone esters (T) were administered from day 0 (To), and additional animals were administered either T, 17beta-oestradiol benzoate (EB) or diethylstilbestrol (DES) for 1 or 4 h on day 6 after EDS-treatment. Nuclear immunoexpression of the androgen receptor (AR) was reduced or absent from the testis but unaffected in the ventral prostate following these treatments. ERbeta immunoexpression in these tissues was unchanged. Northern blot analysis showed that EB and DES as well as T administration 4 h earlier could modulate mRNA expression of two androgen-responsive genes, C3 and SGP-2, in the prostate. The co-administration of T or EB with the AR antagonist, flutamide, or with the ER antagonist, ICI 182,780 (ICI), did not block the suppression of SGP-2 mRNA expression by T or EB. In contrast, the upregulation of C3 mRNA expression by T was successfully antagonised by both flutamide and by ICI. A preliminary evaluation of the expression of three Sertoli cell and five germ cell mRNAs revealed that their expression was not steroid regulated. Our results support the hypothesis that the action of testosterone in the male reproductive system may in part be mediated by its conversion to oestradiol. This in vivo model should prove of value in future studies to identify androgen and oestrogen regulated genes in the male reproductive system.

The development of articular cartilage: evidence for an appositional growth mechanism

It is well-established that cartilage grows by a combination of matrix secretion, cell hypertrophy and cell proliferation. The extent to which this growth is by appositional, as opposed to interstitial mechanisms, however, remains unclear. Using the knee joints of the marsupial Monodelphis domestica to study cartilage growth, we have combined an immunohistochemical study of the TGF-beta family of cartilage growth and differentiation factors between 30 days postpartum to 8 months, together with a stereological analysis of cartilage morphology during growth. Furthermore, to gain an insight into the generation of the characteristic zones within cartilage, we have examined the effects of intra-articular administration of bromodeoxyuridine, an agent that is incorporated into DNA during cell division and blocks further cell cycling. During early growth, TGF-beta2 and -beta3 were widely expressed but TGF-beta1 was less so. After the formation of the secondary centre of ossification, all isoforms became more restricted to the upper half of the tissue depth and their distribution was similar to that previously described for IGFs, and PCNA-positive cells. Stereological analysis of tissue sections from the femoral condylar cartilage at 3 and 6 months showed that there was a 17% increase in total cartilage volume but a 31% decrease in cell density on a unit volume basis. Finally, cell-cycle perturbation with BrDU, which was injected into the knee joints of 3-month-old animals and analysed 1 and 4 months post-injection, revealed that the chondrocytes occupying the transitional zone were depleted 1 month post-injection, resulting in thinning of the articular cartilage. This effect was reversed 4 months post-injection. Immunohistochemical analysis revealed that BrDU-treatment altered the expression patterns of all TGF-beta isoforms, with a marked reduction in labelling of TGF-beta1 and -beta3 isoforms in the upper half of the cartilage depth. Overall, the data lends further support to the notion of articular cartilage growing by apposition from the articular surface rather than by interstitial mechanisms.

Pharmaceutically-based severity stratification of an asthmatic population

Algorithms designed to precisely identify disease severity for a given patient within a managed care population are helpful in organizing targeted interventions. These algorithms are also attracting considerable attention within the medical research community. Several health risk screening instruments have been developed; however, these involve survey methodologies and have several shortcomings. We present a valid and efficient method for predicting healthcare resource utilization among asthmatics in an Health Maintenance Organization (HMO) population. First, various diagnosis, procedure and pharmacy billing codes were used to identify the asthmatics within the database. The screening algorithm awards points each time one of these codes is identified for an HMO member. By varying the number of points necessary to consider a patient asthmatic, the sensitivity, specificity, positive and negative predictive values of the algorithm can be adjusted. Once identified as asthmatic, subjects were then stratified into severity levels based on pharmacy data. Severity stratification was validated directly by measuring asthma-related bed days utilized during the 12 months following the date of stratification. Our identification algorithm estimated an asthma prevalence of 3.84% within the studied population, with age-specific prevalence estimates that closely mirrored previously published survey data. There was a monotonic relationship between pharmacy severity levels and inpatient resource utilization. For example, asthmatics in severity level 1 used only 92 hospital days per 1000 asthmatics in the year following characterization, while those in levels 2-5 used 133, 156, 277 and 1168 hospital days (P < 0.001), respectively. Results from this model can be used as adjusters in other predictive models or stand alone to represent a patient's severity of illness.

Mechanisms of GDF-5 action during skeletal development

Mutations in GDF-5, a member of the TGF-beta superfamily, result in the autosomal recessive syndromes brachypod (bp) in mice and Hunter-Thompson and Grebe-type chondrodysplasias in humans. These syndromes are all characterised by the shortening of the appendicular skeleton and loss or abnormal development of some joints. To investigate how GDF-5 controls skeletogenesis, we overexpressed GDF-5 during chick limb development using the retrovirus, RCASBP. This resulted in up to a 37.5% increase in length of the skeletal elements, which was predominantly due to an increase in the number of chondrocytes. By injecting virus at different stages of development, we show that GDF-5 can increase both the size of the early cartilage condensation and the later developing skeletal element. Using in vitro micromass cultures as a model system to study the early steps of chondrogenesis, we show that GDF-5 increases chondrogenesis in a dose-dependent manner. We did not detect changes in proliferation. However, cell suspension cultures showed that GDF-5 might act at these stages by increasing cell adhesion, a critical determinant of early chondrogenesis. In contrast, pulse labelling experiments of GDF-5-infected limbs showed that at later stages of skeletal development GDF-5 can increase proliferation of chondrocytes. Thus, here we show two mechanisms of how GDF-5 may control different stages of skeletogenesis. Finally, our data show that levels of GDF-5 expression/activity are important in controlling the size of skeletal elements and provides a possible explanation for the variation in the severity of skeletal defects resulting from mutations in GDF-5.

Screening mammography: experience in a health maintenance organization

PURPOSE

To evaluate (a) the relationship between mammogram interpretation and diagnosis of new breast cancer and (b) interprovider variation in mammogram interpretation.

MATERIALS AND METHODS

Interpretations of screening mammograms (133,668 mammograms in 114,899 women) acquired during 21 months in a large health maintenance organization were categorized (categories 1-5) with use of a standard format. During 1 year after mammography, new breast cancer was identified with use of claims data. Interprovider variation in the categories read was evaluated, and percentages of these categories were correlated with breast cancer detection.

RESULTS

Over the 21 months, 1,018 mammograms were followed by a diagnosis of new breast cancer. The category of mammogram interpretation was strongly associated with the diagnosis of new breast cancer; in 47.5% cases of category 5 mammograms, breast cancer was diagnosed. There was substantial interprovider variation in the percentages of category 3, 4, or 5 mammograms read. The percentage of category 4 and 5 mammograms read correlated inversely with the likelihood of cancer detection (Pearson correlation coefficient [r] = -.4778 after log-log transformation, P < .001).

CONCLUSION

A strong correlation existed between a mammographic abnormality suggestive of cancer and its detection; however, substantial interprovider variation in the reading of category 3, 4, and 5 mammograms and their positive predictive values existed. Reduction of interprovider variation should improve quality of care because the number of false-negative and false-positive mammograms should decrease.

Evaluation of an algorithm to identify women with carcinoma of the breast

Although claims data are increasingly being used to measure and manage the cost and quality of health care, few studies have evaluated algorithms developed for such analyses. Therefore, the present study was performed to evaluate prospectively a previously published algorithm used to identify women with the new diagnosis of carcinoma of the breast. This algorithm had been developed from the patterns of claims that suggested common clinical presentations of carcinoma of the breast. In the present study, this algorithm was used to identify 177 potential cases of women with newly diagnosed carcinoma of the breast from the claims database of a large health maintenance organization (HMO). The algorithm's positive predictive value for cases identified in the present study was 83% (147/177). To attempt to improve upon the positive predictive value, multiple modifications of the algorithm were performed. The previously defined best modification of the initial algorithm yielded a positive predictive value of 84% (147/174) in the present study with the loss of none of the true positive cases. These results demonstrate that logic-based algorithms can be used as a valid and efficient method of identifying large numbers of new breast cancer cases from claims data. This algorithm provides a powerful tool to perform health care analysis and research for women with newly diagnosed carcinoma of the breast.

Acceptance and perceptions of NORPLANT among users in San Francisco, USA

Two hundred and five women participating in a five-year clinical trial of NORPLANT and NORPLANT-2 were interviewed about their contraceptive and reproductive history, sources of information and knowledge of NORPLANT, experiences using the method, and the impressions of friends and family about the method. The most common reasons for trying the implants were dissatisfaction with other methods and perceptions about NORPLANT's ease of use. Forty-one percent of acceptors had anxiety prior to insertion; 49 percent of these feared pain, but only 5 percent said that they actually experienced significant pain. Women also feared implant removal, but their fear did not influence their decision to continue or discontinue use, and 74 percent reported little or no pain at removal. Most of the women were pleased with NORPLANT, although 95 percent reported side effects, with 82 percent reporting changes in menstruation. More than one-half of those women who discontinued reported that they would use the implants again. Seventy-four percent of the current users interviewed said they would like to use the implants in the future. For the women enrolled in the clinical trial, NORPLANT appeared to be a highly acceptable method of contraception, despite the frequent occurrence of bothersome side effects.

Abortion training in U.S. obstetrics and gynecology residency programs

The majority (72 percent) of U.S. residency programs in obstetrics and gynecology include first-trimester abortion techniques in their training. Programs affiliated with public hospitals or with private non-Catholic institutions are the most likely to provide such training, while Catholic-affiliated training programs and those at military hospitals are the least likely to do so. Approximately 23 percent of institutions include abortion training as a routine part of residency, and 50 percent offer it as optional training. The 28 percent of residency programs that offer no abortion training represents an almost fourfold increase since 1976. Although more of the large programs affiliated with public hospitals now include such training as a routine part of their residency programs, fewer of the private non-Catholic programs--where the largest proportion of residents are trained--do so. Consequently, the number of residents exposed to abortion training may have declined slightly over the past decade. Little difference exists between the proportion of programs that offer training in first-trimester techniques and the proportion that train in second-trimester techniques. Nine percent of programs report that all residents participate in first-trimester abortion training, and another 56 percent report that at least half of their residents do so. The participation rate is linked to the expectations of the program: Approximately 88 percent of programs that routinely incorporate abortion techniques in their training report that from one-half to all their residents participate, compared with about 55 percent of programs that offer the training as an option. Approximately 82 percent of programs teach abortion techniques up to at least 20 weeks' gestation.(ABSTRACT TRUNCATED AT 250 WORDS)

Should patients be shaved prior to transurethral surgery?

In a prospective randomised trial no significant difference in urinary infection was found when routine pubic shaving prior to transurethral surgery was compared with no pubic shave. An argument based on financial and aesthetic considerations is presented to support the abolition of this traditional policy.